imaging pulmonary infection, classic sign and pattern presentasi

8/9/2019 Imaging Pulmonary Infection, Classic Sign and Pattern PRESENTASI

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CHRISTOPHER M. WALKER, GERALD F. ABBOTT,REGINALD E. GREENE ET AL

AJR:202, MARCH 2014

Imag!g P"#m$!a%& I!'()*$!:C#a++) Sg!+ a! Pa**(%!+


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Introduction

Pulmonary infectionsmost common infections

Centers for Disease Control and Preventioninfluenza & pneumonia8th COD in US (2!!"

Ima#in# studiesdia#nosis & mana#ement $hen ima#in# manifestations of a %non disease

entity form a consistent pattern or characteristicregarded as an imaging sign of disease.


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Ima#in# si#nssometimes nonspecificmay 'emanifestations of noninfectious diseases

)arious ima#in# si#ns of thoracic infection

clinically usefulsu##estin# specific dia#nosis &often narroin# DD*

Clinical data+ ($,C count+ micro'iolo#ic tests+ &immune status"correlated ith ima#in# si#n &

additional findin#saccurate dia#nosis


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O'-ectives

Discuss common & uncommon si#ns and findin#s ofpulmonary infection at radio#raphy and C.+

Discuss the mechanisms and pathophysiolo#ic

factors that produce those findin#s+ /i#hli#ht several noninfectious diseases that may

present ith similar findin#s

.his revie is divided into si#ns that are most

commonly seen or associated ith 'acterial+ viral+fun#al+ and parasitic infections


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Consolidation &0ir,roncho#ram Si#n

Consolidationalveolar1fillin# process that replacesair ithin the affected airspacesincreasin#pulmonary attenuation & o'scurin# the mar#ins of

ad-acent airays and vessels on radio#raphs & C. Consolidationone of the more common

manifestations of pulmonary infectionappearanceis varia'ledependent causative or#anism


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0ir1filled 'ronchivisi'lesurrounded 'y dense+consolidated lun# parenchymaair 'roncho#ramsi#n (i# !"+

3ormal lun#air1filled 'ronchi are not apparenton chest radio#raphssurrounded 'y aerated lun#parenchyma


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Fg. 1-4/&(a%/$# ma! * #('* #$(% #$( 3!("m$!a. Eam3#( $' a%'roncho#ram si#n Posteroanterior radio#raph (left) and coronal CT image (right)sho left loer lo'e consolidation and air 'roncho#ram si#n (arrows).


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Patient ith fever & cou#hsu##ests pneumonia

4ost commonly 'acterial infectionany infectioncan manifest air 'roncho#ram si#n

DD* 3ono'structive atelectasis+

0spiration+

3eoplasms (adenocarcinoma & lymphoma"


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Differentiate atelectasis from pneumonia loo%in#for direct &' indirect si#ns of volume loss ,ronchovascular crodin#

issural displacement

4ediastinal shift

Diaphra#matic elevation

Detection of air 'roncho#ram si#n ar#ues a#ainst the

presence of a central o'structin# lesion


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Silhouette Si#n

.he silhouette si#nanatomic localization ofa'normalities on ortho#onal chest radio#raphs

.he silhouette si#nloss of normal lun#5soft1

tissue interface (loss of silhouette"caused 'y anypatholo#ic mechanism that replaces or displaces air

ithin the lun# parenchyma

Silhouette si#n occurs between structures in the

same anatomic planeithin an ima#e


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Commonly appliedinterface 'eteen lun#s andheart+ mediastinum+ chest all+ and diaphra#m

67ample+ lin#ular pneumonia o'scures the left1heart

'order+& middle lo'e pneumonia o'scures the ri#ht1heart 'order consolidation and the heart 'ordersaresame anatomic plane (i# 2"


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Fg. 2-4/&(a%/$# g%# * #!g"#a% 3!("m$!a. Eam3#( $' +#$"(**( +g!.Posteroanterior radio#raphs sho normal interface (right) and loss of normalinterface of lun# and left1heart 'order (left), thus localizing abnormality to lingula.


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Dia#nosis of 'acterial pneumoniapatient ithfever and cou#h

Other diseases

atelectasis (se#mental or lo'ar"+ aspiration+

pleural effusion+

tumor


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T%((/!/B" Sg!

Small airays or terminal 'ronchiolesinvisibleon C.small size (9 2 mm" & thin alls (9 !mm"

Indirectly visible on C.filled ith mucus+ pus+fluid+ or cells+ formin# impactionsresem'le a'uddin# tree ith 'ranchin# nodular )1 & :1shapedopacitiestree1in1'ud si#n (i# ;"


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Fg. 5-46/&(a%/$# ma! * %(a)*7a*$! *"(%)"#$++. Eam3#( $' *%((/!/" si#n Photo#raph (top) shows budding tree. Axial CT image (bottom) showsnumerous )1 and :1shaped tree1in1'ud opacities


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,ecause tree in1 'ud opacities form in the center ofthe secondary pulmonary lo'ule+characteristicallyspare the su'pleural lun# parenchyma+ includin#that ad-acent to interlo'ar fissures

Initially dia#nostic of myco'acterial infectionmay'e manifestation of various infections'acteria+fun#i+ parasites+ and viruses


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.ree1in1'ud opacitiesindicate infectious'ronchiolitis or aspiration

Other conditions

follicular 'ronchiolitis chronic airays inflammation (cystic fi'rosis or immune

deficiency"

diffuse pan'ronchiolitis+

adenocarcinoma 0spirationdependent tree1in1'ud opacities

predominatin# in the loer lun# zones


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Cystic fi'rosisupper1lun#1zone5predominant'ronchiectasis+ 'ronchial all thic%enin#+ mucusplu##in#+ & mosaic attenuation

Diffuse pan'ronchiolitis

diffuse and uniform tree1in1'ud opacities6ast 0sian descent


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Fg. 4-40/&(a%/$# ma! a'*(% I8 !9()*$! $' )%"+( morphine sulfate ta'lets 67ample oftree1in1'ud si#n 07ial ma7imum1intensity1pro-ection ima#e shos diffuse vascular tree1in1'udopacities and dilated main pulmonary arteries Similar findin#s involved all aspects of 'oth lun#sInfectious 'ronchiolitis or aspiration is unli%ely to result in such diffuse 'ilateral distri'ution of tree1in1'ud opacities+ and other conditions+ such as diffuse pan'ronchiolitis and in-ection of forei#nmaterial+ as in this case+ should 'e considered as alternative dia#noses


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,ul#in# issure Si#n

.he 'ul#in# fissure si#ne7pansive lo'arconsolidationfissural 'ul#in# *displacement 'ycopious amounts of inflammatory e7udate ithin theaffected parenchyma

Classicallyri#ht upper lo'e consolidation due toKlebsiella pneumoniae (ig. !).

.he si#n is fre>uentlypneumococcal pneumonia


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Fg. 6-6/&(a%/$# ma! * a#)$$#+m a! Klebsiella pneumonia. Example of bulgingfissure sign. Posteroanterior (left) and lateral (right) radiographs show right upper lobeconsolidation causing inferior'ul#in# of minor fissure (blac" arrows), posterior bulging of ma#orfissure (white arrow), and inferomedial displacement of 'ronchus intermedius (asteris").


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.he prevalence of this si#n is decreasin#administration of anti'iotic therapy

Other diseasesspace1occupyin# process in the

lun# (pulmonary hemorrha#e+ lun# a'scess+ andtumor"


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eedin# )essel Si#n

eedin# vessel si#nC. findin# of a pulmonaryvessel coursin# to a distal pulmonary nodule ormass

Ori#inally thou#ht to indicate hemato#enousdissemination of disease'ut on 4P?actuallypulmonary veins coursin# from the nodule pulmonary arteries coursed around the nodule

Initially considered dia#nostic of septic em'oli (i#

@" Other conditions+metastasis+ arteriovenous fistula

& pulmonary vasculitis


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Fg. ;-46/&(a%/$# ma! * +(3*) (m$#. Eam3#( $' '((!g 7(++(# +g!.Coronal C. ima#e shos septic pulmonary em'oli manifestin# themselves asperipheral solid and cavitary pulmonary nodules of varyin# sizes 4any nodules

e7hi'it feedin# vessel si#n (arrows).


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Septic em'olithe feedin# vessel si#n is seen ithcavitatin# and noncavitatin# nodules and su'pleural

ed#e1shaped consolidation

3odules

'asal & peripheral

vary in size 0rteriovenous fistulafindin# feedin# artery &

enlar#ed drainin# vein


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Inhomo#eneous 6nhancementSi#n and Cavitation

Patient ith pneumonia+ C. detection ofinhomo#eneous enhancement & cavitationnecrotizin# infection

Pulmonary necrosis

hypoenhancin# #eo#raphicareas of lo lun# attenuation that may 'e difficult todifferentiate from ad-acent pleural fluid (i# A"

.his findin#'efore fran% a'scess formation and is

a predictor of a prolon#ed hospital course


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Fg. -66/&(a%/$# ma! * !()%$*


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0 cavitya'normal lucency ithin an area ofconsolidation ith or ithout air1fluid level

Cavitationresult of suppurative or caseous

necrosis or lun# infarction Importantly+ cavitation does not always indicate a

lun# infection or a'scess

Cavitation can have noninfectious causes + mali#nancy+

radiation therapy+

lun# infarction


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Suppurative necrosis$taphylococcus aureus,gramnegati%e'acteria+ or anaero'es

Caseous necrosischaracteristic histolo#ic feature

of myco'acterial infection+ Cavitationcommon patholo#ic and ima#in#

feature of an#ioinvasive fun#al infections(asper#illosis & mucormycosis"


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0ir1luid


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Detection of an air1fluid level at chest radio#raphyevaluation of its location as 'ein# in the lun#parenchyma or ithin the pleural space

0 lun# a'scess ith an air1fluid level can bedifferentiatedfrom empyema ith 'ronchopleuralfistula 'y measurement and comparison of thelengths of the %isualized air&fluid le%el on

orthogonal chest radiographs.


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Characteristic +3(%)a#shape of a lung abscess+ anassociated air1fluid level typically has equallengthson posteroanterior and lateral chestradio#raphs (i# 8"

,y contrast+ empyematypically forms #(!*)"#a%collections of pleural fluid+ and an associated air1fluid level (e#+ 'ronchopleural fistula" usually

exhibits length disparityhen compared onposteroanterior and lateral chest radio#raphs


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i# 8B;1year1old man ith$taphylococcus aureus pneumonia forming lung abscess.'xample of air&fluid le%el sign.0+ Posteroanterior (left) and lateral (right) radiographs show right lower lobe ca%ity with air&fluidle%el (arrows) of eual length on both orthogonal %iews. Thic", irregularall typical of lun# a'scessis evident,+ 07ial C. ima#e shos parenchymal location of ri#ht loer lo'e cavity ith air1fluid level+ irre#ularinternal contours+ and associated 'ronchus (arrow) coursing to lesion.

A B


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Split1Pleura Si#n

3ormal visceral & parietal pleuraindistin#uisha'le on C.

In presence of an e7udative pleural effusion ith

loculation+ inflammatory chan#es

thic%en 'oth thevisceral & parietal pleura that surround the fluidcollectionsplit1pleura si#nempyema


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Split1pleura si#n may 'e seencom'ination ithair1fluid level si#n hen a 'ronchopleural fistulaoccurs ithin empyema

6mpyema

hen a patient presents ith fever+cou#h+ and chest pain and C. shos split1pleurasi#n

In 8 patients ith empyema+ the splitpleura si#n

as seen in @8 (i# E"


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Fg. -4=/&(a%/$# $ma! * (m3&(ma. Eam3#( $' +3#*/3#("%a +g!. Aa# (left) andsagittal (right) contrast&enhanced CT images show thic"ened %isceral (arrowhead) and parietal(white arrows) pleura separated from their normal state of apposition (ie+ split" to surroundloculated empyema 0d-acent atelectasis is evident in ri#ht loer lo'e Split1pleura si#n is not specificfor empyema 'ut rather indicates presence of e7udative effusion Chest tu'e is incompletely visi'le

(blac" arrows).


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Other important causes parapneumonic and mali#nant effusions (i# !"+

hemothora7+

se>uelae of previous talc pleurodesis+ lo'ectomy+ or

pneumonectomy

/emothora7hetero#eneously hi#h attenuation+and talc pleurodesisattenuation similar to alcium& often clumped


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Fg. 10-;6/&(a%/$# ma! * ma#g!a!* 3#("%a# (''"+$!. Eam3#( $' +3#*/3#("%asi#n 07ial (left) and sagittal (right) contrast&enhanced CT images show thic"eningof visceral (arrowheads) and parietal (arrows) pleura with associated effusion.Split1pleura si#n only indicates presence of e7udative effusion and must 'ecorrelated ith clinical findin#s and thoracentesis to esta'lish accurate dia#nosis


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Ha#$ Sg!

.he halo si#nC. findin# of a peripheral rim of#round1#lass opacity surroundin# a pulmonarynodule or mass

In a fe'rile patient & neutropenia

hi#hlysu##estive of an#ioinvasive Aspergillus infection(ig.!!"

Fround1#lass opacityhemorrha#e surroundin#

infarcted lun#vascular invasion 'y the fun#us /alo si#ntypically seen early in the course of

the infection


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Fg. 11-56/&(a%/$# ma! * '(7(%, !("*%$3(!a, a! a!g$!7a+7(Aspergillus infection 67ample of halo si#n Posteroanterior radio#raph and a7ial C.ima#e sho ri#ht upper lo'e mass ith peripheral #round1#lass opacity (arrows)constitutin# halo si#n


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In lar#e #roup of immunocompromised patients ithAspergillus infection+ Freene and collea#uespatients in hom the halo si#n as visualized at C.improved survival and response to antifun#al

Differential considerations for the halo si#n includeother infections 4ucormycosis and Candida (ig. *), +seudomonas,

/erpes simple7 virus+ Cytome#alovirus infections+ Other ($e#ener #ranulomatosis+ hemorrha#ic metastasis+ and

Gaposi sarcoma"


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Fg. 12-4/&(a%/$# ma! * ++(m!a*( )a!a++. Eam3#( $' a#$+g!.07ial C. ima#e shos multiple 'ilateral pulmonary nodules ith surroundin##round1#lass opacity

A C * S ' A


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A% C%(+)(!* Sg! $' A!g$!7a+7(Aspergillus Infection

.he air crescent si#n C. findin# of a crescenticcollection of air that separates a nodule or mass fromthe all of a surroundin# cavity

.his si#n

to types ofAspergillus infectionangioin%asi%e and mycetoma

In an#ioinvasiveAspergillus infectioncaused 'yparenchymal cavitationoccurs 2 ee%s after

detection of initial radio#raphiccoincides ith thereturn of neutrophil function (i# !;"


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Fg. 15-5=/&(a%/$# ma! * a!g$!7a+7(Aspergillus infection. Exampleof air crescent si#n 07ial (left) and coronal (right) CT images show air crescent si#n(arrows), which occurs in immunocompromised patients with reco%ering neutrophillevels Intracavitary nodule (asteris"s) represents necrotic lung tissue.


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0ir crescent si#nsu##estive of favora'le pro#nosis

Intracavitary nodulenecrotic+ retracted lun#tissueseparated from peripheral via'le

/emorrha#ic lun# parenchyma seen as outerconsolidation or #round1#lass opacity

A% C%(+)(!* $% M$!a Sg!


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A% C%(+)(!* $% M$!a Sg!$' M&)(*$ma

.he air crescent si#n of mycetoma+the 4onad si#nin immunocompetent host ith pree7istin# cysticor cavitary lun# disease+ usually from tu'erculosis orsarcoidosis

.he fun#al 'all or mycetoma develops ithin apree7istin# lun# cavity and may e7hi'it #ravitydependence (i# !="


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Fg. 14-;6/&(a%/$# $ma! * !*%a)a7*a%& m&)(*$ma. Eam3#( $' a%crescent or 4onad si#n 07ial supine (left) and prone (right) CT images show#ravity dependence of fun#al 'all (mycetoma" 0ir crescent si#n of mycetomaoccurs in immunocompetent patients un#us 'all develops ithin pree7istin#cavity+ usually in association ith tu'erculosis or sarcoidosis


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.he mycetomafun#al hyphae+ mucus+ and cellularde'ris

4ycetomas can cause hemoptysis

.reatmentsur#ical resection+ 'ronchial arteryem'olization & instillation of antifun#al a#ents into thecavity

.he air crescent si#n is not specific forAspergillusinfectionother conditions cavitatin# neoplasm+

intracavitary clot+

$e#ener #ranulomatosis


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in#er1in1Flove Si#n

.he fin#er1in1#love si#nchest radio#raphicfindin# of tu'ular & 'ranchin# tu'ular opacities thatappear to emanate from the hila#loved fin#ers

.he tu'ular opacities represent dilated 'ronchiimpacted ith mucus

.he C. fin#er1in1#love si#n'ranchin#endo'ronchial opacities that course alon#side

nei#h'orin# pulmonary arteries


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.he findin# is classically associated ith 0ller#ic 'ronchopulmonary asper#illosis (0,P0"+ seen in

persons ith asthma and patients ith cystic fi'rosis (i# !"+

4anifestation of endo'ronchial tumor (i# !@"+

,ronchial atresia+ Cystic fi'rosis+

Postinflammatory 'ronchiectasis

,ronchoscopy may 'e necessary to e7cludeendo'ronchial tumor as the cause of the fin#er1in1#love si#n


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Fg. 16-26/&(a%/$#oman ith aller#ic 'ronchopulmonary asper#illosis (0,P0"67ample of fin#er1in#love si#n

A, P$+*(%$a!*(%$% radio#raph shos 'ranchin# tu'ular opacities (arrows) emanatin#from 'oth hilaB, >!(!a!)( aa# (left) and obliue sagittal (right) CT images show'ranchin#tu'ular opacities (arrows)ith hi#h attenuation Opacities in 0,P0 are composed of


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Fg. 1;-;5/&(a%/$# ma! * +?"am$"+ )(## #"!g )a!)(%. Eam3#( $' '!g(%/!g#$7( si#n Posteroanterior radio#raph (top left) and corresponding coronal (topright) and axial (bottom) CT images show branching tubular opacity (arrows) in ri#htupper lo'e Pro7imal portion of 'ranchin# opacity as DF avid (not shon" andrepresented tumor+ hereas rest of opacity represented mucoid impaction in dilated'ronchus


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C%a


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0ncillary clinical or radio#raphic features su##estiveof+neumocystis pneumonia includea history ofimmunosuppression+ ima#in# findin#s of pulmonarycysts+ and the occurrence of secondary spontaneous

pneumothora7 (i# !A"


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Fg. 1-24/&(a%/$# ma! * HI8 !'()*$! a!+neumocystis pneumonia.'xample of crazy&pa%ing si#n 07ial C. ima#e shos diffuse #round1#lass opacity ithareas of superimposed interlo'ular septal thic%enin# (com'ination that formscrazypavin# pattern" and multiple thin1alled cysts In /I)1positive patient ithdyspnea+ findin#s are most consistent ith+neumocystis pneumonia.


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Differential dia#nosticcrazy1pavin# si#n can 'ecate#orized accordin# to the typical time course ofthe suspected diseases (i# !8"

0cutepulmonary edema+ pulmonary hemorrha#e+and infection

Chronic coursepulmonary alveolar proteinosis+pulmonary adenocarcinoma+ and lipoid pneumonia


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Fg. 1=-CT +)a!+ +$ )%a


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Frape1S%in Si#n

.he #rape1s%in si#nradio#raphic or C. findin# ofa very thin1alled cavitary lesiondevelops in lun#parenchyma previously affected 'y consolidation orlun# #ranulomasunder#one central caseous

necrosis

0s classically descri'ed+ #rape1s%in si#nsolitaryfindin# of a thin1alled cavity ith central lucency

associated ith chronic pulmonarycoccidioidomycosis infection (i# !E"


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Fg. 1-66/&(a%/$# ma! * )%$!) coccidioidomycosis infection 67ample of#rape1s%in si#n Posteroanterior radio#raph shos thin1alled #rape1s%in cyst (arrows).Axial CT image (inset) shos that over time cavity may deflate and ac>uire sli#htlythic%er all


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Over time the lesion may deflate+ or it may ruptureinto the pleural spacepneumothora7

Differential dia#nosis ?eactivation tu'erculosis infection+

Pneumatocele+

3eoplasm (primary lun# cancer or metastasis"+

Other fun#al infections


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M#a%& Pa**(%!

.he miliary patternmultiple small (9 ; mm"pulmonary nodules of similar sizerandomlydistri'uted throu#hout 'oth lun#s

.his patternhemato#enous dissemination ofdiseaseclassically associated ith .,'ut canalso 'e seen ith other infections (histoplasmosis &coccidioidomycosis+ particularly in

immunocompromised (i# 2"


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Fg. 20-2/&(a%/$# ma! * AIDS @CD4 )$"!*, !*


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?andom pulmonary nodules must 'e differentiatedfrom those ith a centrilo'ular or perilymphaticdistri'ution

Centrilobularnodules are evenly spaced and donot come into contact ith ad-acent pleuralsurfaces

Perilymphaticnodules are distri'uted alon#

peri'ronchovascular structures+ the su'pleural lun#+and alon# interlo'ular septa


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andom nodules formin# the miliary pattern aredistri'uted uniformly throu#hout the lun#s+ andthose in the periphery may come into contact ith apleural surface

3oninfectious causesmetastatic disease+ I)in-ected forei#n material+ and rarely sarcoidosis

#


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R(7(%+( Ha#$ a! B%+ N(+* Sg!+

.he reverse halo si#nC. findin# of peripheralconsolidation surroundin# a central area of #round1#lass opacity

0ssociated irre#ular and intersectin# areas ofstrandin# or irre#ular lines may 'e present ithinthe area of #round1#lass opacity and 'ecome evidentas the 'irdHs nest si#n (i# 2!"

.hese si#nssu##estive of invasive fun#al infection(e#+ an#ioinvasiveAspergillus infection ormucormycosis)


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Fg. 21-44/&(a%/$# ma! * '(%#( !("*%$3(!a a! 3"#m$!a%&m")$%m&)$++. 67ample of reverse halo and 'irdHs nest si#ns 07ial (left) and coronal(right) CT ima#es sho peripheral rim of consolidation (arrows) surrounding centralgroundglass opacity+ reticulation+ and nodularity .his appearance has 'een li%enedto 'irdHs nest and reverse halo 6arly dia#nosis of mucormycosis pneumonia isimperative 'ecause standard voriconazole therapy is not effective for treatment


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.he reverse halo and 'irdHs nest si#ns are not specificfor invasive fun#al infection and may also 'e seen inother conditions+ Crypto#enic or#anizin# pneumonia+

,acterial pneumonia+

Paracoccidioidomycosis+

.u'erculosis+

Sarcoidosis+

$e#ener #ranulomatosis+

Pulmonary infarction

M(!+)"+, C"m$, a! Wa*(% L#&


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, , &Sg!+ $' E)!$)$))a# I!'()*$!

Pulmonary hydatid diseasezoonotic parasiticinfectionlarval sta#e of'chinococcustapeworms.

This genus of orms is endemic in 0las%a+ South0merica+ the 4editerranean re#ion+ 0frica+ and0ustralia

/umans can serve as intermediate hosts after

contact ith a definitive host (e#+ do# or olf" orafter consumin# contaminated ve#eta'les or ater


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.he lun#second most common or#an involved+ after theliverinfected 'y either hemato#enous or directtransdiaphra#matic spread from the liver

.he hydatid cyst is composed of three layers

an outer protective 'arriermodified host cells+ called the pericystK a middle acellular laminated mem'rane+ called the ectocystK

and an inner #erminal layerproduces scolices+ hydatid fluid+ dau#htervesicles+ and dau#hter cysts+ called the endocyst


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.he meniscus+ Cum'o+ and ater lily si#ns are allseen ith pulmonary echinococcal infection

.hese si#ns are caused 'y air dissectin# 'eteen thecyst layers+ hich are initially indistin#uisha'le onC. ima#es 'ecause the cysts are fluid filled (i# 22"

$ith 'ronchial erosion+ air dissects 'eteen theouter pericyst and ectocyst to produce the meniscus

si#n (i# 2;"


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Fg. 22-D%a!g+ +$ !$%ma# &a* )&+* a! m(!+)"+, C"m$,a! a*(% ##& +g!+.


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Fg. 25-4/&(a%/$# ma! * 3"#m$!a%& &a* +(a+(. Eam3#( $' m(!+)"+(left) and Cumbo (right) signs. Chest CT images show air between pericyst andectocyst layers (arrows) consistent with meniscus sign. Air&fluid le%el in endocyst(arrowhead) in combination with meniscus sign forms Cumbo sign. (Courtesy of?ossi S+ Centro de Dia#nostico Dr 6nri>ue ?ossi+ ,uenos 0ires+ 0r#entina"


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Some radiolo#ists 'elieve that the meniscus si#n issu##estive of impendin# cyst rupture

0s it accumulates further+ air penetrates theendocyst layer and causes the Cum'o si#n+ hichcomprises an air1fluid level in the endocyst and ameniscus si#n (i# 2;"

inally+ the endocyst layer collapses and floats on

fluid+ formin# the ater lily si#n (i# 2="


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Fg. 24-2/&(a%/$# $ma! * 3"#m$!a%& &a* disease 67ample of aterlily si#n Posteroanterior radio#raph shos lar#e ri#ht loer lo'e thic%1alled cavity ithlo'ulated air5soft1tissue interface representin# floatin# endocyst (arrow). Coronal C.ima#e (inset) from earlier examination shows unruptured cyst

B %%$ Sg! $' Pa%ag$!ma++


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B"%%$ Sg! $' Pa%ag$!ma++

Para#onimiasis is a zoonotic parasitic infectioncaused 'y lun# flu%es

/umans serve as a definitive host hen they in#estra or improperly coo%ed cra' or crayfish

+aragonimus westermani and +aragonimus"ellicotti are the two pathogens endemic to0sia and3orth 0merica+ respectively .hey produce similar

ima#in# findin#s in the thora7


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.he chest C. findin#s reflect the life cycle of the parasite.he second form of the immature or#anism lives in the cra'

or crayfish 0fter in#estion 'y a mammal+ the parasitepenetrates throu#h the small 'oel to enter the peritoneal

cavity+ here it incites an inflammatory reactionSeveral ee%s later+ the or#anism mi#rates throu#h the

diaphra#m to enter the pleural space


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0fter findin# mates+ the parasites 'urro throu#h thevisceral pleura into the lun# parenchyma+ here theyproduce cysts that contain e##s

.he e##s are e7truded into 'ronchioles and e7pectorated 'y

the infected mammal to complete the life cycle.he 'urro si#nlinear trac% e7tendin# from the pleural

surface or hemidiaphra#m to a cavitary or cystic pulmonarynodule

.he linear trac% represents the path folloed 'y the ormsithin the lun#+ and the cavitary or cystic pulmonary nodulecontains 'oth the adult orms and their e##s (i# 2"


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Fg. 26-52/&(a%/$# ma! * N$%* Am(%)a! 3a%ag$!ma++ a'*(%!g(+*$! $' %a )%a&'+. Eam3#( $' "%%$ +g!.

A, Aa# CT mag(+ ! +$'*/*++"( @left! and lung "right! windows showslinear burrow trac# "arrows! extending from thic#ened pleura to pulmonarynoduleB, Aa# CT mag( +$+ #$!g #!(a% "%%$ *%a) @arrow! in right upper

lobe and small pneumothorax.


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.here is often associated pleural effusion+ omentalfat strandin#+ and anterior cardiophrenic andinternal mammary lymphadenopathy

Patients occasionally present ith pneumothora7

?eco#nizin# the linear 'urro trac% is the %ey todifferentiatin# this entity from others+ such asmali#nancy+ fun#al infection+ and tu'erculosis

C$!)#"+$!


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C$!)#"+$!

Ima#in# plays an important role in the dia#nosis of suspected

pulmonary infection and may reveal useful si#ns at chestradio#raphy and C.

Si#ns such as the ater lily and 'urro si#ns almost alaysindicate a specific infection+ hereas findin#s such as the split1pleura si#n often su##est a specific dia#nosis of empyema in theclinical settin# of pneumonia

Several si#ns+ such as the halo and reverse halo si#ns+ may indicatepotentially serious fun#al infections in an immunocompromisedpatient

Ima#in# si#ns of lun# a'scess+ such the an air1fluid level si#n in acavity+ may also 'e predictive of pro#nosis and #uide duration oftherapy


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.han% :ou

imaging pulmonary infection, classic sign and pattern presentasi

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