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23

Radiographic
Findings
Neonatal
Pneumonia

Phillip J. Haney1
Mark Bohlman2
Chen-Chih
J. Suns

in

The chest films of 30 infants with autopsy-proved

pulmonary
infections were reviewed
to assess the radiographic
changes
in neonatal
pneumonia.
The most common abnormality identified was bilateral
alveolar densities,
noted in 77% of cases. One-third of
patients had characteristically
extensive,
dense alveolar
changes
with numerous
air
bronchograms.
A pattern
of radiographic
abnormalities
consistent
with transient tachypnea of the newborn
was found in 17% of cases,
and a second
pattern
resembling
hyaline membrane
disease was found in 13%. Recognition
of the spectrum
of expected
radiographic
changes can aid in the diagnosis
of neonatal
pneumonia,
particularly
if this
information
is correlated
with the clinical features.
a

Although
morbidity
because
changes
membrane
resulting

pulmonary
infection
constitutes
a continuing
and significant
source of
and mortality
in the neonate,
radiographic
diagnosis
remains
difficult
of the wide range of nonspecific
changes
that can occur [1, 2]. These
often may mimic those of more benign
conditions,
such as hyaline
disease
and transient
respiratory
distress
syndrome
of the newborn,
in delayed
diagnosis
unless
strongly
suggestive
clinical
features
are

present.

In order

their relative
of 30 infants

Materials
Autopsy

researched
identified

and

9, 1983; accepted

after

revision

Department
of Diagnostic Radiology, University
of Maryland Hospital, 22 S. Greene St., Baltimore,
MD 21201. Address reprint requests toP. J. Haney.
2Depment
pitals,

Baltimore,

of Radiology,

Baltimore

City Hos-

MD 21224.

3Department
of Pathology, University
land Hospital, Baltimore, MD 21201.

AJR 143:23-26, July 1984

0361-803x/84/1431-0023
$2.00
C American Roentgen Ray Society

of Mary-

the

spectrum

of expected

radiographic

analysis

changes

and

of the chest

films

Methods

records from two institutions

to identify cases of pneumonia.
in which

the

only

significant

supporting

large

neonatal

referral

centers

were

From the period 1975 to 1981 , 34 cases were

pathologic

abnOrmality

was

evidence

of pneumonia.

disease, meconium aspiration, or other noninfectious

abnormality
were not included. The histologic findings consisted of polymorphonuclear
leukocytic infiltration in the alveolar spaces and alveolar septa, often associated with cellular
necrosis and fibrin deposition.
Bacteria were present in some cases. Cases initially reported
as questionable
or probable
were reexamined
before
inclusion
in the study. The chest
radiographs were then reviewed by two of us (PH. , M.B.). Four cases were excluded from
Cases demonstrating

Received
June
March 5, 1984.

to assess

incidences,
we undertook
a retrospective
with autopsy-proved
neonatal
pneumonias.

hyaline

membrane

the study because the films were unavailable

In all cases, at least one chest radiograph

or technically

suboptimal.

was available on the final day of life, and in most

cases, multiple studies were obtained within hours of the patients death. Death occurred on
the average at 3 days (range, 1-5 days). The last radiograph obtained before death was used
in the analysis
of findings.
A chart reviewed
revealed
that all infants
had one or more
predisposing
factors
or clinical
indications
of infection:
prolonged
premature
rupture
of
membranes (93%), leukocytosis
(76%), positive blood cultures (66%), nonpulmonary
infections (40%), matemal
infection
(30%), fever or hypothermia
(30%), infected amniotic fluid
(20%), nonstenle
delivery
(10%). There were no instances of meconium aspiration.
Most

blood culture results were available only after death. Various degrees of respiratory
were present in all cases; apnea and bradycardia occurred in 66% of patients.

distress

HANEY

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24

Fig. 1.-Dense
bilateral alveolar infiltrates with air bronchograms and obof cardiac and diaphragmatic contours, at age 3 days. 6 hr before
death.
scuration

TABLE

1: Radiographic

Findings in Neonatal

ET AL.

AJR:143, July 1984

Fig. 2.-Bilateral
than those

alveolar densities

and air bronchograms

less extensive

in fig. 1. Final film on day 4 of life.

Pneumonia
No. (%)

Alveolar densities
Dense bilateralwith air bronchograms
Patchy bilateral
Right greater than left
Central, perihilar distribution
Air bronchograms
Pulmonary
interstitial
emphysema
Overinflation
Granular densities (hyaline membrane
disease)
Dilated vessels
Pneumothorax
Pleural effusion
Normal
Thickened
minor fissure
Pneumomediastinum
Bilateral reticular densities

23 (77)
10 (33)
3 (10)

(7)

1 (3)
15 (50)

7 (23)
5
4
3
3
3
3
3
1
1

(17)
(13)
(10)
(10)
(10)
(10)
(10)
(3)
(3)

Fig. 3.-Granular
densities with air bronchograms
brane disease, at age 3 days, 4 hr before death.

Results

The radiographic
findings
are listed in table 1 The most
common
abnormality
identified
was bilateral
alveolar densities, found in 77% of patients.
These were extensive
and
dense with air bronchograms
in 10 patients (33%) and were
less dense but bilateral and confluent
in 24% (figs. 1 and 2).
Bilateral
patchy,
segmental
densities
were found in three
patients
(10%). The alveolar
densities
were predominantly
right-sided
in two patients
and had a central, perihilar distnbution in one. Air bronchograms
were noted in one-half
of

resembling hyaline mem-

cases, and generalized

pulmonary
ovennflation
was present
in five (1 7%). Pleural fluid was seen in 1 0% of patients,
although
decubitus
views were not available.
Diffuse, fine granular densities
were present in four cases
(13%) resulting
in a pattern
indistinguishable
from hyaline
membrane
disease (fig. 3). Three patients
(10%) had dilated
pulmonary
vessels suggestive
of retained fetal lung fluid or a
left-to-right
shunt. Various combinations
of pulmonary
over-

NEONATAL

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AJR:143, July 1984

Fig. 4.-A,
before death.

25

PNEUMONIA

Initial film on day 1 of life. Well inflated lungs with no other abnormalities.

B, Film on day 3. Development

of overinflation

and dilated vessels 12 hr

inflation,
dilated vessels,
thickened
minor fissure,
air-space
filling, and pleural fluid produced
typical findings
of transient
tachypnea
of the newborn
in five patients
(17%) (fig. 4).
Bilateral fine reticular densities
were noted in one patient.
There were two unilateral
and one bilateral
pneumothoraces in the series. Complications
of mechanical
ventilation

patient management,
definitive radiographic
evidence of pneumonia would
be of considerable
value.
Unfortunately
the
previously
reported
changes
on chest film have shown
a
broad and varied spectrum
of abnormalities;
normal chest,
localized
or diffuse alveolar densities,
interstitial
lung disease,
and changes
identical
to hyaline membrane
disease
have all

also were found;

been described

interstitial
patients

there were seven examples

emphysema

of pulmonary

and one pneumomediastinum.

Three

(10%) had normal chest films.

Discussion
Despite

recent

advances

in therapy

of neonatal

infections,

pneumonia
remains a principal cause of death in the newborn,
with an incidence of 22%-23%
in unselected
infant autopsies
[3, 4]. Most pneumonias
result from an ascending
vaginal
infection
associated
with prolonged
labor and premature
rupture of the membranes,
although
the infection
occasionally
may be acquired
hematogenously
or during vaginal passage
[1 1 Premature
infants are affected
more often than full-term
infants. Symptoms
vary; the infant may be stillborn or manifest
immediate
severe
respiratory
distress
in some
cases,
whereas
in others
the only indication
of disease
may be
hypothermia.
Early diagnosis
requires
identification
of pathogenic organisms
in the amnion,
gastric aspirate,
or tracheal
aspirate.
Percutaneous
lung aspiration
also has been suggested
as a direct method
of establishing
the presence
of
].

infection,

but

requires

some

prior

localizing

not currently
used in our institutions.
Since early recognition
of these

information

infections

and

is critical

is

in

[2, 5]. The results

of our study

confirm

this

diversity
of radiographic
changes
in neonatal
pneumonia
but
also suggest
some helpful
patterns
of involvement.
Over
three-quarters
of cases showed bilateral alveolar densities as
the major radiographic
finding. The single most frequent
and
characteristic
pattern of alveolar change was that of a very
dense, bilateral
air-space
filling process
with numerous
air
bronchograms;
this was seen in 33% of our patients.
Most of
the remaining
cases with alveolar
densities
showed
milder
degrees
of involvement,
but again
with diffuse
bilateral
changes.
Three cases (1 0%) were less uniform,
with patchy,
segmental
densities
of the type seen in adult bronchopneumonia. Of interest are two cases in which alveolar involvement
was

predominantly

right-sided,

a pattern

analogous

to the

recently
described
right-sided
predominance
in some cases
of delayed
clearance
of fetal lung fluid [6]. Finally, a single
patient displayed
a central,
perihilar
distribution
of alveolar
densities
mimicking
pulmonary
edema.
A pattern of granular densities
with air bronchograms
indistinguishable
from hyaline membrane
disease
was noted in
four patients
(13%), precluding
a radiographic
diagnosis
of

pneumonia on the basis of pulmonary parenchymal

changes
alone. Typical complications
of respiratory therapy also were
seen in this group; interstitial emphysema,
pneumomedias-

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26

HANEY

tinum, and pneumothorax

were seen predominantly
with the
granular pattern but also developed
in some cases with purely
alveolar changes.
Another
pattern of radiographic
changes,
identical to that of transient
tachypnea
of the newborn,
was
found in five patients (1 7%). Differentiation
between
transient
tachypnea
and pneumonia
was possible only by examination
of serial films. In cases
of pneumonia,
the radiographic
changes developed
after an initially normal study or persisted
beyond the usual 1 -2 day duration
of transient
tachypnia.
Leonidas et al. [7] reported that pleural effusions
are common
but not specific in pulmonary
infections
caused by group B
Streptococcus.
Three of our patients (1 0%) had evidence
of
pleural fluid on routine supine chest films; two of these had
underlying
radiographic
changes
of hyaline membrane
disease and the third mimicked
transient
tachypnea.
Since all of our cases were based on autopsy findings,
the
results are probably
skewed
to represent
the more serious
types of infection.
Nevertheless,
our results indicate that there
are several radiographic
findings that may be of considerable
value in diagnosing
pneumonia,
particularly
in infants
with
predisposing
conditions
and clinical features.
Dense, bilateral
air-space filling with air bronchograms
is a common and rather
characteristic
radiographic
finding
in neonatal
pneumonia.
Less pronounced,
diffuse, bilateral alveolar densities
are also
frequently
present,
occasionally
tending
to a patchy,
unilat-

ET AL.

AJR:143, July 1984

eral, or central distribution.

Radiographic
changes
of hyaline
membrane
disease
may be distinguished
from pneumonia
occasionally
by the presence
of a pleural effusion.
Finally, an
unusually late development
of the transient
tachypnea
pattern
or persistence
of changes
beyond 1 -2 days should suggest
the presence
of infection.
REFERENCES
1 . Avery ME, Fletcher BD, Williams RG. The lung and its disorders
in the newborn infant, 4th ed. Philadelphia:
Saunders,
1981:203-

221
2. Swischuk

LE. Radiology
of the newborn
and young infant, 2d
ed. Baltimore:
Williams & Wilkins, 1980:69-74
3. Benirschke
K. Routes and types of infectionin the fetus and the
newborn. Am J Dis Child 1960;99:714-720
4. Naeye RL, Dellinger WS, Blanc WA. Fetal and maternal features
of antenatal bacterial infections. J Pediatr 1971;79:733-739
5. Ablow RC, Gross I, Effmann

EL, Uauy A, Driscoll S. The radio-

logic features
of early onset group B streptococcal
neonatal
sepsis. Radiology
1977;1 24:771-777
6. Swischuk LE, Hayden CK, Richardson
CJ. Neonatal opaque
right lung: delayed fluid resorption.
Radiology
1981;141 :671673
7. Leonidas JC, Hall AT, Beatty EC, Fellows RA. Radiographic
findingin early onset neonatal gruop B streptococcal septicemia.
Pediatrics
1977;59: 1006-1011