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
PACS, BIDMC PACS, BIDMC
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
PACS, BIDMC PACS, BIDMC
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
PACS, BIDMC PACS, BIDMC
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
PACS, BIDMC
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.