Joseph Garland, HMS IVGillian Lieberman, MD

Round Pneumonia

Joseph Garland, HMS IVGillian Lieberman, MD

Joseph Garland, HMS IVGillian Lieberman, MD

Case 1: Mr. H

Mr. H is a 45-year-old man who presents with a 4 day history of full-body myalgias, headaches and fever to 103˚F. He also complains of sharp left- sided chest pain worse on deep inspiration.

Joseph Garland, HMS IVGillian Lieberman, MD

Other Relevant Information

ROS: otherwise negative

PMH: asthma, one episode of pneumonia 6m ago requiring hospitalization

SH: Nonsmoker, no IVDU, occasional EtOH.

PE: T=101.6˚F, HR=120. Crackles heard in mid-lung field on the left. Otherwise wnl.

Labs: WBC 19.7, otherwise WNL.

Joseph Garland, HMS IVGillian Lieberman, MD

A chest X-ray was obtained…

Joseph Garland, HMS IVGillian Lieberman, MD

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Mr. H, Chest Radiographs

This was called a LLL pneumonia, cannot rule out infarct or malignancy. Do you agree?

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC PACS, BIDMC

Mr. H, Chest Radiographs – Magnification of Lesion

The lateral view suggests the mass is in the lingula.

Joseph Garland, HMS IVGillian Lieberman, MD

The patient went on to have a CT scan…Why?

Joseph Garland, HMS IVGillian Lieberman, MD

The Solitary Pulmonary Nodule

Neoplastic (malignant or benign)

Bronchogenic carcinoma

Metastasis

Lymphoma

Carcinoid

Hamartoma

Connective tissue and neural tumors - Fibroma, neurofibroma, blastoma, sarcoma

Inflammatory (infectious)

Granuloma - TB, histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis, nocardiosis

Lung abscess

Round pneumonia

Hydatid cyst

Inflammatory (noninfectious)

Rheumatoid arthritis

Wegener granulomatosis

Sarcoidosis

Lipoid pneumonia

Congenital

Arteriovenous malformation

Sequestration

Lung cyst

Miscellaneous

Pulmonary infarct

Round atelectasis

Mucoid impaction

Progressive massive fibrosis

Reference: Sharma S, Navaratnam S. “Solitary Pulmonary Nodule.” E-Medicine. 2004. http://www.emedicine.com

Has a lengthy differential…

Joseph Garland, HMS IVGillian Lieberman, MD

In this case, we are most worried about differentiating

Pneumonia (based on clinical presentation)

and

Bronchogenic carcinoma(the most concerning possibility)

Joseph Garland, HMS IVGillian Lieberman, MD

Mr H, CT with IV contrast

PACS, BIDMC

Joseph Garland, HMS IVGillian Lieberman, MD

Mr H, CT with IV contrast

Major fissure

R intermediate bronchus

Inferior lobar bronchus

Superior division Lingular

bronchus

PACS, BIDMC

Joseph Garland, HMS IVGillian Lieberman, MD

Mr H, Coronal CT with IV contrast

5.6 x 2.9 cm peripheral area of consolidation in the lingula

PACS, BIDMC

Joseph Garland, HMS IVGillian Lieberman, MD

Treatment started for CAP

Mr H was started on Levofloxacin 500 mg PO QD for clinical pneumonia.

His CXR and CT could not rule out malignancy.

He clinically improved and returned for a follow-up Chest X-ray two months later…

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC PACS, BIDMC

Mr. H, Follow-up Chest Radiographs (2 months later)

The lesion has resolved. The pleural thickening on the left is unchanged in 4 yrs.

Joseph Garland, HMS IVGillian Lieberman, MD

Case 2: Mr. G.

Mr G is a 75 yo man who presented to the emergency department with a fever to 104˚F and chills x 1 day, and mild shortness of breath.

Joseph Garland, HMS IVGillian Lieberman, MD

Other Relevant Information

ROS: otherwise unremarkable

PMH: CAD s/p MI (1y ago), Hypertension, permanent pacemaker

SH: 20 pack-year smoking history, quit 30y ago

PE: VS are stable, rest of exam is normal

Labs: WBC of 20.9, otherwise WNL

Joseph Garland, HMS IVGillian Lieberman, MD

As part of a fever workup, a chest X-ray was obtained…

Joseph Garland, HMS IVGillian Lieberman, MD

2.5 m poorly-defined noduleLeft Upper Lobe

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Mr. G, Chest Radiographs

Joseph Garland, HMS IVGillian Lieberman, MD

What should the next step be?

Clinical presentations suggestive respiratory tract infection.

Chest radiograph findings are atypical for (but not inconsistent with) pneumonia.

Again, the major concern is “benign vs malignant?”

Joseph Garland, HMS IVGillian Lieberman, MD

The patient went on to have a CT scan…

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr G, CT without contrast

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr G, CT without contrast

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr G, CT without contrast

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr G, CT without contrast

Tethering of the major fissure

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr G, CT without contrast

Joseph Garland, HMS IVGillian Lieberman, MD

Air bronchogram

Mr G, CT without contrast – Soft Tissue Window

PACS, BIDMC

Joseph Garland, HMS IVGillian Lieberman, MD

Findings

Findings may be consistent with round pneumonia, but are suggestive of invasive adenocarcinoma with bronchioloalveolar component. Also consider post-obstructive pneumonia.

Pt was started on Levofloxacin 500mg PO QD for 14 days.

He was scheduled for CT-guided biopsy but, after clinical improvement, this was postponed.

Joseph Garland, HMS IVGillian Lieberman, MD

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Mr. G, Follow-up Chest Radiographs (2 weeks later)

Joseph Garland, HMS IVGillian Lieberman, MD

PACS, BIDMC

Mr. G, Initial and Follow-up Chest Radiographs

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Initial Presentation 2 weeks later, s/p antibiotics

Though still present, the nodule has partially resolved. A follow-up in 4w was recommended.

Joseph Garland, HMS IVGillian Lieberman, MD

Round Pneumonia

First reported in the radiology literature in 1954 (though it was mentioned in the surgical literature in 1940).

Describes any pneumonia presenting as a nodule or “coin lesion”

It is rare, it accounts for less than 1% of “coin lesions” of the lung

Joseph Garland, HMS IVGillian Lieberman, MD

Varied Clinical Presentations

Presentation may be with acute or subacute symptoms of community- acquired pneumonia

Symptoms may also be mild, mimicking a viral syndrome or bronchitis

Patients may even be completely asymptomatic.

Joseph Garland, HMS IVGillian Lieberman, MD

Radiologic Features

On Chest films: Rounded lesion. Air bronchograms may be present. They are only present in 17% of patients with round pneumonia and are not generally helpful because they can also be seen in adenocarcinoma and bronchioloalveolar carcinoma.

Recent Chest films are often helpful. 2-3cm masses that appeared in the last 2-6 weeks are more likely infectious than neoplastic.

On CT: heterogeneous mass of soft-tissue attenuation that can have spicules, air bronchograms, pleural thickening and satellite lesions.

Joseph Garland, HMS IVGillian Lieberman, MD

Pediatric Round Pneumonia

Round pneumonia is more commonly a disease of children. It is a diagnosis considered in younger patients with classic clinical picture of pneumonia and a coin lesion on chest film.

Children rarely get a CT if the clinical picture fits.

Joseph Garland, HMS IVGillian Lieberman, MD

Pediatric case of Round Pneumonia

Courtesy Dr. Jason Handwerker, BIDMC Courtesy Dr. Jason Handwerker, BIDMC

A typical presentation for this would be a very high fever in a child.

Joseph Garland, HMS IVGillian Lieberman, MD

Theories on Formation

Round pneumonia may result from an infectious focus that spreads centrifugally through the pores of Kohn and canals of Lambert, or by destroying the walls of alveoli.

However, children have underdeveloped pores of Kohn and canals of Lambert, suggesting that in children, the “roundness” may actually occur because the lack of interalveolar pathways limits the spread of the organism.

Round pneumonia may also represent incomplete resolution of a lobar pneumonia.

Joseph Garland, HMS IVGillian Lieberman, MD

Relevant Anatomy

Pores of Kohn: openings in the alveolar walls connecting adjacent alveolar lumens

Canals of Lambert: connections between terminal bronchioles and adjacent alveoli

They allow for collateral ventilation and also are a means of bacterial spread in the lungs. Adapted from http://www.mevis.de/~hhj/Lunge/ima/InfKohnP.htm

Joseph Garland, HMS IVGillian Lieberman, MD

The Offending Agents

Usually Streptococcus pneumoniae

There are also reports of Klebsiella pneumoniae, Mycobacterium tuberculosis, and Coxiella burnetii (Q fever) presenting with a round pneumonia.

Joseph Garland, HMS IVGillian Lieberman, MD

Treatment

Standard treatment with antibiotics that cover Strep. pneumoniae pneumonia should suffice.

Always order a follow-up chest film to document resolution of the lesion, and to rule out a malignant process.

Joseph Garland, HMS IVGillian Lieberman, MD

When to Consider Round Pneumonia

Suspect round pneumonia in an adult patient who present with a pulmonary mass, especially if s/he has respiratory infection symptoms, is a young nonsmoker, and has no other findings to suggest malignancy. A recent normal chest radiograph is also helpful.

Remember! Any patient with a pulmonary nodule that does not decrease in size or resolution after antibiotic treatment should be further assessed with bronchoscopy or transthoracic needle biopsy.

Joseph Garland, HMS IVGillian Lieberman, MD

Courtesy Dr. Andetta Hunsaker, BWH

41-year-old female nonsmoker with fever and bibasilar rales.

Joseph Garland, HMS IVGillian Lieberman, MD

References

Ackerman LV, et al. 1954. “Localized Organizing Pneumonia: Its Resemblance to Carcinoma.” AJR. 71(6): 988-996.

Antón E. 2004. “A Frequent Error in Etiology of Round Pneumonia.” Chest. 125:1592-1593

Durning SJ, et al. 2003. “Pulmonary Mass in Tachypneic, Febrile Adult.” Chest. 124:372-375.

Greenfield H, Gyepes MT. 1964. “Oval-Shaped Consolidation Simulating New Growth of the Lung” AJR. 91(1):125-129.

Lossos IS, Breuer R. 1989. “Round Pneumonia.” Isr J Med Sci. 25:713-714.

Fox LA, Hunsaker AR. 1997. “Localized Organizing (Round) Pneumonia.” BrighamRad. http://brighamrad.harvard.edu/Cases/bwh/hcache/210/full.html

Price J. 1999. “Round Pneumonia and Focal Organizing Pneumonia are Different Entities.” AJR. 172:549.

Sharma S, Navaratnam S. 2004. “Solitary Pulmonary Nodule.” E-medicine. http://www.emedicine.com

Wagner AL, et al. 1998. “Radiologic Manifestations of Round Pneumonia in Adults.” AJR. 170:723-726.

http://oac.med.jhmi.edu/Pathology/Idmicro/Bacteria/137B.html

http://www.mevis.de/~hhj/Lunge/ima/InfKohnP.htm

Beth Israel Deaconess Medical Center PACS system.

Joseph Garland, HMS IVGillian Lieberman, MD

Special Thanks

Dr. Maryellen Sun, BIDMC.

Dr. Phillip Boiselle, BIDMC.

Dr. Jason Handwerker, BIDMC.

Dr. Andetta Hunsaker, BWH.

Ms. Pamela Lepkowski, BIDMC.