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Necrotizing Pneumonia
Claudio Karsulovic, Universidad de Chile Year VII
Gillian Lieberman, MD
October 2010Claudio Karsulovic, VIIGillian Lieberman, MD
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Our Patient: History (part I)
• 59 year‐old male, smoker, no significant past medical history, with recent diagnosis of non‐ small cell lung cancer.
• He underwent Chemoradiation therapy due to locally advanced disease in mediastinoscopy
Claudio Karsulovic, VIIGillian Lieberman, MD
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Our Patient: First Chest CT
• Spiculated left hilar
mass encasing the
distal main
left pulmonary
artery.
Claudio Karsulovic, VIIGillian Lieberman, MD
3AXIAL, C+, CHEST CTPACS, BIDMC
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Claudio Karsulovic, VIIGillian Lieberman, MD
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Our Patient: PET‐SCAN
CORONAL, FDG, PET‐SCANPACS, BIDMC
Large, 4 cm FDG avid left hilar mass, with invasion into mediastinal structures
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Our Patient: History (part II)
Claudio Karsulovic, VIIGillian Lieberman, MD
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• During 2nd chemoradiation cycle, patient presents to the ED with fever, cough, chills,
night sweats and left sided pleuritic pain
• Physical exam is significant for left‐sided rales and left chest tenderness to palpation
• Immunocompetent (undergoing chemotherapy)
• A Chest CT was ordered
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Chest CT Findings
Let’s see the Chest CT findings in our patient…
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Claudio Karsulovic, VIIGillian Lieberman, MD
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Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
81
Our Patient: Chest CT Severe Paraseptal Emphysema
Severe paraseptal emphysema
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
AXIAL, C+, CHEST CTPACS, BIDMC
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Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
101
Our Patient: Chest CT Cavitating Consolidation
Consolidation in superior segment of LLL with septated space, containing air and air
broncogram
AXIAL, C+, CHEST CTPACS, BIDMC
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
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Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
121
Our Patient: Chest CT Ground‐Glass Infiltrates
Peribronchial ground‐glass opacification in the RUL.
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
AXIAL, C+, CHEST CTPACS, BIDMC
131
Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
141
Our Patient: Chest CT Subsegmental Atelectasis
Subsegmental atelectasis in the lateral basal segment, local bronchial inflammation and
bronchial wall thickening.
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
AXIAL, C+, CHEST CTPACS, BIDMC
151
Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
161
Our Patient: Chest CT Residual Tumor
Residual peribronchial tumor infiltration in the mediastinum along the left main
bronchus
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
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Our patient: Summary Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
Let’s check out some important Topics…
181
Our patient: Topic Review
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia• Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
Let’s talk a little about different types of Emphysema…
191
Types of Emphysema: Paraseptal
Features:
•Distal airway
•Along the septae and pleura
•Airflow preserved
•Associated with spontaneous pneumothorax (SP)
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
History spotlights of SP:
•Young
•Tall
•Thin
•Acute chest pain
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Types of Emphysema: Panacinar
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C‐, CHEST CTPACS, BIDMC
AAT Deficiency:
•AAT protects Elastin from destruction by
Neutrophils´ Elastase
•Without AAT, tissue lose compliance and are
more fragile
•Severe form: < 10% of fuctional enzyme
•Suspect in: Young patient with Cirrhosis +
Emphysema
Features:
•Destruction of entire alveolus
•Predominates in lower half of the lungs
•Associated with AAT (alpha 1 antitripsin) deficiency (homozygous)
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Types of Emphysema: Centriacinar
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C‐, CHEST CTPACS, BIDMC
Tobacco:•Cause airway inflammation increasing neutrophil chemotaxis
•Diminish in Elastin/Elastase ratio
•Accelerated destruction of parenchyma
Features:
•Starts in bronchioles and spreads peripherally
•Predominates in upper half of the lungs
•Associated with long-standing cigarette smoking
Let’s continue with our patient findings…
221
Our patient: Findings Summary
Claudio Karsulovic, VIIGillian Lieberman, MD
22
• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia • Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
Let’s talk a little about a Cavitating Infective Consolidation…
231
Cavitating Infective Consolidation: Main Points
Associated most commonly with aspiration
and/or
Impaired local or systemic immune response.
•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22‐25.
Claudio Karsulovic, VIIGillian Lieberman, MD
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Cavitating Infective Consolidation: Radiological features
•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22‐25.
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Most commonly: Apicoposterior aspect
of the UL or the apical segment of the
LL.
• Spherical area of consolidation >2 cm in
diameter.
• Usually an air‐fluid level present.
• Thick and Irregular wall.
• Abscesses abutting the pleura form
acute angles.
• The cavitation does not cross fissures
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Cavitating Infective Consolidation: DDX
Necrotizing Infections
Anaerobic bacteria
Other Bacteria Staphylococcus aureus, Enterobacteriaceae,
Pseudomona aeruginosa, Legionella, HiB, Nocardia,
Actinomyces
Mycobacteria M. tuberculosis, M. avium, M. Kansasii
Fungi Aspergillus, Coccidiodes, Histoplasma, Blastomyces,
Cryptococcus, Mucor, Pneumocystis carinii
Non‐Infectious Causes
Bland embolism with infarction
Vasculitis
Neoplasm
Pulmonary sequestration
Bullae o Cysts with air fluid level
Bronchiectasis
Empyema with air fluid level
Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009
Claudio Karsulovic, VIIGillian Lieberman, MD
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Our patient: Findings Summary
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema• Cavitation in a large region of left lung concerning for
Necrotizing Pneumonia • Small pneumonic foci in the RUL• New LLL bronchial inflammation and distal atelectasis • Stable tumor, predominantly surrounding the left main
bronchus
What is the most likely cause in our patient?...
271
Necrotizing Infections
Anaerobic bac
Other Bac Staphylococcus aureus, Enterobacteriaceae,
Pseudomona aeruginosa, Legionella, HiB, Nocardia,
Actinomyces
Mycobacteria M. tuberculosis, M. avium, M. Kansasii
Fungi Aspergillus, Coccidiodes, Histoplasma, Blastomyces,
Cryptococcus, Mucor, Pneumocystis carinii
Non‐Infectious
Bland embolism with infarction
Vasculitis
Neoplasm
Pulmonary sequestration
Bullae o Cysts with air fluid level
Bronchiectasis
Empyema with air fluid level
Our patient: DDX
Ruled Out
We know that our patient has NSCLC under treatment and has presented with fever, chills and productive cough
Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009
Claudio Karsulovic, VIIGillian Lieberman, MD
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Let’s continue with the follow‐up…
281
Our Patient: 2 weeks follow‐up…
Claudio Karsulovic, VIIGillian Lieberman, MD
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Our Patient: 2 weeks follow‐up note
• Not responsive to antibiotics: Vancomycin + Piperacillin‐Tazobactam
• Positive Galactomannan
• A follow‐up Chest CT was ordered
Claudio Karsulovic, VIIGillian Lieberman, MD
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Let’s see the findings on follow‐up images…
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Our patient: 2 weeks follow‐up Chest CT Findings Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema
• Cavitating consolidation
• Ground‐glass infiltrates in the RUL
311
Our Patient: 2 weeks Follow‐up Chest CT Paraseptal Emphysema
Severe paraseptal emphysema
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
SCOUT, C+, CHEST CTPACS, BIDMC
321
Our patient: 2 weeks follow‐up Chest CT Findings Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema
• Cavitating consolidation
• Ground‐glass infiltrates in the RUL
331
Our Patient: 2 weeks Follow‐up Chest CT Cavitating Consolidation
Large cavitary lesion with thick wall in the superior segment of
LLL with a dense
consolidation that extends to the left hilum
AXIAL, C+, CHEST CTPACS, BIDMC
Claudio Karsulovic, VIIGillian Lieberman, MD
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SAGITTAL RECONSTRUCTION, C+, CHEST CTPACS, BIDMC
341
Our patient: 2 weeks follow‐up Chest CT Findings Index
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema
• Cavitating consolidation
• Ground‐glass infiltrates in the RUL
351
Our Patient: 2 weeks Follow‐up Chest CT Ground‐Glass Infiltrates
Patchy ground‐glass infiltrate in the RUL
Claudio Karsulovic, VIIGillian Lieberman, MD
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AXIAL, C+, CHEST CTPACS, BIDMC
AXIAL, C+, CHEST CTPACS, BIDMC
361
Our patient: 2 weeks follow‐up Chest CT Findings
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Severe Paraseptal Emphysema
• Cavitating consolidation
• Ground‐glass infiltrates in the RUL
Let’s review some important points about Necrotizing Pneumonia…
371
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70‐75.
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
381
Necrotizing Pneumonia: Pathophysiology
Thrombotic occlusion of alveolar capillaries associated with
adjacent inflammation, resulting in ischemia and eventually
necrosis of the lung parenchyma.
Tumor inside the vessel
Extrinsic compression
Intraluminal thrombus
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
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391
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
401
• Predisposing risk factor, e.g. aspiration or inmunocrompromised patient
• Cough with purulent sputum.
• Fever.• Failed response to antibiotics.• Indolent course of existing pneumonia.
• Pulmonary neoplastic disease or TB infection.
Necrotizing pneumonia: Clinical Features
•Misra, Rakesh. A-Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press; 2007:22-25.
Claudio Karsulovic, VIIGillian Lieberman, MD
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411
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
41
• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
421
Necrotizing pneumonia: Radiological Features
•Loss of normal pulmonary parenchyma architecture
•Dominant area of consolidation
•Thickened‐wall cavitary lesion
•Low contrast enhancing wall of the cavitary lesion
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
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431
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
43
• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
441
Necrotizing Pneumonia: v/s Lung Abscess
Very controversial topic because for many authors
is considered as one entity
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
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Necrotizing Pneumonia Lung AbscessSevere complication causing necrosis
of lung parenchymaSupurative process with a well‐
defined fibrous wall
Low contrast enhancing wall in Chest
CTContrast enhancing wall in Chest CT
Thick wall > 2 cm with or without air‐
fluid levelThick wall > 2cm, with air‐fluid level
Loss of normal lung parenchyma Normal pulmonary parenchyma
architecture
451
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
45
• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
461
Necrotizing Pneumonia: Infectious causes
Anaerobes
Most common cause
Associated with aspiration
Aerobes
•MRSA
Associated with Panton Valentine Leukocidine (PVL)
Present as a community‐acquire pathogen in the US
•E.Coli
•S.Pneumoniae
•Pseudomona aeruginosa
Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009Bartlett JG. Anaerobic Bacterial Infections in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009
Claudio Karsulovic, VIIGillian Lieberman, MD
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471
Necrotizing Pneumonia: Summary Index
Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1): 70-75.
Claudio Karsulovic, VIIGillian Lieberman, MD
47
• Pathophysiology• Clinical Features• Radiological Features• Lung Abscess v/s Necrotizing Pneumonia
• Infectious Causes
Let’s continue with our patient’s history…
481
Our Patient: 3 weeks follow‐up…
Claudio Karsulovic, VIIGillian Lieberman, MD
491
Our Patient: 3 weeks follow‐up note
• Change of antibiotic theraphy to: Ceftriaxone 2 gr Q24 + Metronidazol 500 mg Q8
• Antifungical coverage with: Voriconazol 300 mg twice daily
• Stable clinical condition• A follow‐up Chest X Ray was ordered
Claudio Karsulovic, VIIGillian Lieberman, MD
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Let’s see the findings on the follow‐up X ray…
501
Our patient: 3 weeks follow‐up Chest X Ray Findings
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Large medial lucencies (Severe Emphysema)
• Cavitating consolidation
• Focal opacity in the RUL
511
Our patient: 3 weeks follow‐up Chest X Ray Large medial lucencies (Severe Emphysema)
• Large thin‐walled areas
of lucency in the
anterior chest
corresponding to large
areas of bullous disease.
Claudio Karsulovic, VIIGillian Lieberman, MD
51PA VIEW, C‐, CHEST X RAYPACS, BIDMC
LATERAL VIEW, C‐, CHEST X RAYPACS, BIDMC
521
Our patient: 3 weeks follow‐up Chest CT Findings
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Large medial lucencies (Severe Emphysema)
• Cavitating consolidation
• Focal opacity in the RUL
531
Our patient: 3 weeks follow‐up Chest X Ray Cavitating consolidation
• Large lucent lesion
demonstrating a thick
rim of increased
opacity, situated in the
superior segment of the
LLL
Claudio Karsulovic, VIIGillian Lieberman, MD
53PA VIEW, C‐, CHEST X RAYPACS, BIDMC
LATERAL VIEW, C‐, CHEST X RAYPACS, BIDMC
541
Our patient: 3 weeks follow‐up Chest CT Findings
Claudio Karsulovic, VIIGillian Lieberman, MD
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• Large medial lucencies (Severe Emphysema)
• Cavitating consolidation
• Focal opacity in the RUL
551
Our patient: 3 weeks follow‐up Chest X Ray Focal opacity in the RUL
• Focal opacity in the left
lower lung and the right
mid lung.
Claudio Karsulovic, VIIGillian Lieberman, MD
55Do you remember the “Spine Sign”?
LATERAL VIEW, C‐, CHEST X RAYPACS, BIDMC
PA VIEW, C‐, CHEST X RAYPACS, BIDMC
561
Our patient:“Spine Sign”
Claudio Karsulovic, VIIGillian Lieberman, MD
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ZOOM IN IMAGEPACS, BIDMC
But, what finally happened with our patient?
LATERAL VIEW, C‐, CHEST X RAYPACS, BIDMC
571
Necrotizing Infections
Anaerobic bac
Other Bac Staphylococcus aureus, Enterobacteriaceae,
Pseudomona aeruginosa, Legionella, HiB, Nocardia,
Actinomyces
Mycobacteria M. tuberculosis, M. avium, M. Kansasii
Fungi Aspergillus, Coccidiodes, Histoplasma, Blastomyces,
Cryptococcus, Mucor, Pneumocystis carinii
Non‐Infectious
Bland embolism with infarction
Vasculitis
Neoplasm
Pulmonary sequestration
Bullae o Cysts with air fluid level
Bronchiectasis
Empyema with air fluid level
Our patient: Final DDX
Ruled Out
We know that our patient has NSCLC under treatment and he has infectious symptoms
Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009
Claudio Karsulovic, VIIGillian Lieberman, MD
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UnlikelyNegative cultures and Non‐responsive to ATBs,
but still is the most common cause
Possible: Positive Galactomannan and indolent evolution
581
Our Patient: 3 weeks follow‐up note
• Stable clinical condition
• Slow improvement with new theraphy
• Follow‐up with Pulmonary and Infectious Disease teams for monitoring and serial
imaging
Claudio Karsulovic, VIIGillian Lieberman, MD
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Acknowledgements
• Carole Ridge, MD
• Gillian Lieberman, MD
• Ada Gropper, HMS IV
• Scott Zimmer, MD
• Emily Hanson, Educational Coordinator
• Our webmaster: Larry Barbaras
Claudio Karsulovic, VIIGillian Lieberman, MD
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References•Lozano, J. Complicaciones Asociadas a Neumonia Bacteriana. Neumologia Pediatrica. 2010; 5(Sup1):
70‐75.
•Misra, Rakesh. A‐Z of Chest Radiology. First Edition. New York, NY. Cambridge University Press;
2007:22‐25.
•Sawicki GS, Lu FL, Valim C. Necrotising pneumonia is an increasingly detected complication of
pneumonia in children. Eur Respir J 2008; 31: 1285–1291
•Mahfouz, M. Necrotizing Pneumonia: Sequential Findings on Chest Radiography.
EJB 2009: 3: 86‐89
•Kim EA, Lee KS, Shim YM. Radiographic and CT findings in complications following pulmonary
resection. Radiographics.
2002 Jan‐Feb;22(1):67‐86
•Labandeira‐Rey M, et al. Staphylococcus aureus Panton‐Valentine Leukocidin Causes Necrotizing
Pneumonia. Science. 2007 Feb 23;315(5815):1130‐3
•Kim DH, Lee JH, Kim BH. Chronic necrotizing bronchopulmonary aspergillosis with elements of
bronchocentric granulomatosis.
Korean J Intern Med. 2002 Jun;17(2):138‐42.
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References•Gillet Y, Issartel B, Vanhems P. Association between Staphylococcus aureus
strains carrying gene for
Panton‐Valentine leukocidin
and highly lethal necrotising
pneumonia in young immunocompetent
patients. Lancet. 2002 Mar 2;359(9308):753‐9.
•Roberts JC, Gulino
SP, Peak KK. Fatal necrotizing pneumonia due to a Panton‐Valentine leukocidin
positive community‐associated methicillin‐sensitive Staphylococcus aureus
and Influenza co‐
infection: a case report. Ann Clin Microbiol Antimicrob. 2008 Feb 19;7:5.
•Vayalumkal
JV, Whittingham H, Vanderkooi
O. Necrotizing pneumonia and septic shock: suspecting
CA‐MRSA in patients presenting to Canadian emergency departments. CJEM. 2007 Jul;9(4):300‐3.
•Bartlett JG. Lung Abscess in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA, 2009
•Bartlett JG. Anaerobic Bacterial Infections in: UpToDate, Bartlett JG (Ed), UpToDate, Waltham, MA,
2009
•Macedo M, Meyer KF, Oliveira TC. Necrotizing pneumonia in children submitted to thoracoscopy
due
to pleural empyema: incidence, treatment and clinical evolution. J Bras Pneumol. 2010 Jun;36(3):301‐
5.
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