Air crescent sign of mycetoma occurs in immunocompetent patients. Intracavitary nodule (asterisks) represents necrotic lung tissue. Patients occasionally present with pneumothorax [79–83]. Caseous necrosis is a characteristic histologic feature of mycobacterial infection, but cavitation is a common pathologic and imaging feature of angioinvasive fungal infections, such as aspergillosis and mucormycosis. Pneumonia is the most common cause of death due to infectious diseases in the United States, with an incidence of 11.6 per 1000 persons/year reported in one study 4. The second form of the immature organism lives in the crab or crayfish. The crazy-paving sign was originally described as a characteristic CT pattern detected in patients with pulmonary alveolar proteinosis. This is seen as increased whiteness, (because of increased density), but not enough to totally obscure lung markings; giving a … Axial CT image shows diffuse ground-glass opacity with areas of superimposed interlobular septal thickening (combination that forms crazy-paving pattern) and multiple thin-walled cysts. Axial CT image (inset) shows that over time cavity may deflate and acquire slightly thicker wall. As it accumulates further, air penetrates the endocyst layer and causes the Cumbo sign, which comprises an air-fluid level in the endocyst and a meniscus sign (Fig. These signs are caused by air dissecting between the cyst layers, which are initially indistinguishable on CT images because the cysts are fluid filled (Fig. Less common forms of infection include cellular bronchiolitis, septic embolism, miliary infection, and lung abscess. They produce similar imaging findings in the thorax [79–83]. Hover on/off image to show/hide findings. Sattar SBA, Sharma S. Bacterial Pneumonia. 13). A lung abscess with an air-fluid level can be differentiated from empyema with bronchopleural fistula by measurement and comparison of the lengths of the visualized air-fluid level on orthogonal chest radiographs. This patient has had positive RT-PCR testing for 2019-nCoV before CT, so CT findings are consistent with COVID-19 pneumonia CO-RADS 6. 25). Example of burrow sign. under- ve hypokalemic diarrheal children admi ed to an . Consolidation seen in a non-lobar distribution should raise the suspicion of atypical organisms; This patient with known HIV infection has subtle consolidation in the mid zones bilaterally bacterial pneumonia than in COVID-19 pneumonia [18, 23] (Fig. Accreditation and Designation Statement The RSNA is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educati… Similar findings involved all aspects of both lungs. The objectives of this article are to discuss common and uncommon signs and findings of pulmonary infection at radiography and CT, discuss the mechanisms and pathophysiologic factors that produce those findings, and highlight several noninfectious diseases that may present with similar findings. [Updated 2020 Mar 6]. Axial (left) and sagittal (right) contrast-enhanced CT images show thickened visceral (arrowhead) and parietal (white arrows) pleura separated from their normal state of apposition (i.e., split) to surround loculated empyema. Fig. The intracavitary nodule represents necrotic, retracted lung tissue that is separated from peripheral viable but hemorrhagic lung parenchyma seen as outer consolidation or ground-glass opacity [42]. Associated irregular and intersecting areas of stranding or irregular lines may be present within the area of ground-glass opacity and become evident as the bird's nest sign [65] (Fig. Detection of the air bronchogram sign argues against the presence of a central obstructing lesion. 3). The silhouette sign was initially described by Felson as a radiographic sign that enabled the anatomic localization of abnormalities on orthogonal chest radiographs [5]. Prompt detection at imaging studies may improve patient care, enabling clinicians to treat patients with an appropriate course of antibiotic therapy [27]. Paragonimiasis is a zoonotic parasitic infection caused by lung flukes [79]. The CT finger-in-glove sign is branching endobronchial opacities that course alongside neighboring pulmonary arteries. Although chest radiographs are still useful as an initial test, their utility is limited in the diagnosis of lu … Abnormal lung opacity 2. 15), but may also occur as an imaging manifestation of endobronchial tumor (Fig. 23). Fig. 11). 2001;18 (1): 196-208. Opacities in ABPA are composed of hyphal masses, and mucoid impaction and may be calcified on CT images in as many as 28% of cases. Split-pleura sign is not specific for empyema but rather indicates presence of exudative effusion. The silhouette sign describes loss of a normal lung–soft-tissue interface (loss of silhouette) caused by any pathologic mechanism that replaces or displaces air within the lung parenchyma. Bacterial pneumonia often manifests with a clinical picture similar to that seen in immunocompetent patients, with new-onset fever, cough, chest and radiologic signs of lobar consolidation, and a rapid rise in the level of inflammatory markers such as CRP. Silhouette signs: Loss of clarity of the diaphragm and heart borders 4. Pneumonia is in contrast to pneumonitis, which is inflammation of the pulmonary interstitium. 2 —4-year-old girl with lingular pneumonia. Moreover, rapid diagnosis can lead to early control of potential transmission, thus … In patients in whom pneumonia was suspected, overall clinical opinion of the chest radiographs did not further increase the likelihood of VAP. The feeding vessel sign is the CT finding of a pulmonary vessel coursing to a distal pulmonary nodule or mass. However, a more insidious or diffuse presentation that is more difficult to differentiate from viral or fungal infection is not uncommon. No pleural effusion. (Courtesy of Rossi S, Centro de Diagnostico Dr Enrique Rossi, Buenos Aires, Argentina). 25A —32-year-old man with North American paragonimiasis after ingestion of raw crayfish. Example of finger-in-glove sign. In Pneumocystis pneumonia, the histologic features that produce the crazy-paving pattern are alveolar exudates containing the infective organisms and cellular infiltration or edema in the alveolar walls and interlobular septa [52, 53]. Uterine Leiomyosarcoma: Can MRI Differentiate Leiomyosarcoma From Benign Leiomyoma Before Treatment? The initial abnormalities suggesting covid-19 pneumonia on a chest radiograph are loss of the normal black appearance in the lung. 20). Increase in the size and number of lung markings 3. The nodules usually have basal and peripheral predominance and vary in size [24]. 12), Pseudomonas, herpes simplex virus, and cytomegalovirus infections, and other causes, such as Wegener granulomatosis, hemorrhagic metastasis, and Kaposi sarcoma [38, 39]. The reverse halo sign is the CT finding of peripheral consolidation surrounding a central area of ground-glass opacity [64]. [8] In a group of 25 patients with invasive Aspergillus infection, the halo sign was seen in 24 patients on day 0 and was detected in only 19% of patients by day 14, highlighting the importance of performing CT early in the course of a suspected fungal infection [36]. Bronchoscopy may be necessary to exclude endobronchial tumor as the cause of the finger-in-glove sign. Pulmonary infections are among the most common infections encountered in outpatient and inpatient clinical care. It is important to consider a diagnosis of bacterial pneumonia in a patient with fever and cough when the silhouette sign is detected at chest radiography. This sign is seen in two types of Aspergillus infection: angioinvasive and mycetoma [40]. Coronal CT image shows septic pulmonary emboli manifesting themselves as peripheral solid and cavitary pulmonary nodules of varying sizes. Fig. (Courtesy of Chou S, University of Washington, Seattle, WA). In a patient with pneumonia, detection of an air-fluid level on chest radiographs or CT images suggests the presence of a lung abscess or empyema with bronchopleural fistula. In patients with chronic symptoms, crazy-paving sign may represent lipoid pneumonia, lung cancer, or pulmonary alveolar proteinosis (PAP). Axial CT image shows multiple small pulmonary nodules distributed uniformly throughout both lungs. After ingestion by a mammal, the parasite penetrates through the small bowel to enter the peritoneal cavity, where it incites an inflammatory reaction. 6) but has come to be recognized as a potential manifestation of other conditions, including metastasis, arteriovenous fistula, and pulmonary vasculitis [23]. In: StatPearls [Internet]. Air-fluid level in endocyst (arrowhead) in combination with meniscus sign forms Cumbo sign. Arteriovenous fistula is differentiated from septic emboli by the finding not only of a feeding artery but also of an enlarged draining vein. Pulmonary necrosis may become evident as hypoenhancing geographic areas of low lung attenuation that may be difficult to differentiate from adjacent pleural fluid [25] (Fig. a The rst CT scan obtained on illness day 4 revealed patchy GGOs in both the lungs. Radiologic Signs on an award-winning, radiologic teaching site for medical students and those starting out in radiology focusing on chest, GI, cardiac and musculoskeletal diseases containing over 200 PowerPoint lectures, quizzes, hand-out notes, interactive material, most commons lists and pictorial differential diagnoses Consolidation that extends to the border of an adjacent soft-tissue structure will obliterate its interface with that structure [5]. From the case: COVID-19 pneumonia. These signs are suggestive of invasive fungal infection (e.g., angioinvasive Aspergillus infection or mucormycosis) in susceptible patient populations [66]. 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