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JOURNAL READING

IMAGING PULMONARY INFECTION:


CLASSIC SIGNS AND PATTERNS
Disusun Oleh :
Philipus Hendry Hartono - 406161017

Pembimbing :
dr. Lia Sasdesi Mangiri, Sp.Rad
Kepaniteraan Klinik Ilmu Radiologi
Rumah Sakit Umum Daerah Semarang
Fakultas Kedokteran Universitas Tarumanagara
Periode 17 Juli 19 Agustus 2017
ABSTRACT
Pulmonary infections are among the most common
infections encountered in outpatient and inpatient
clinical care.
Imaging studies are critical for the diagnosis and
management of pulmonary infections.
Various imaging signs of thoracic infection can be
clinically useful, sometimes suggesting a specific
diagnosis and often narrowing the differential
diagnosis.
ABSTRACT
Clinical data, such as WBC count, results of
microbiologic tests, and immune status, should be
correlated with the imaging sign and any additional
findings to facilitate an accurate diagnosis
OBJECTIVE
The purposes of this article are to describe
common and uncommon imaging signs and
patterns of pulmonary infections and to discuss
their underlying anatomic and pathophysiologic
basis
These signs include for plain films
Consolidation and air Grape-skin sign,
bronchogram sign, Finger-in-glove sign,
Silhouette sign, Westermark sign,
Bulging Fissure Sign, Juxtaphrenic peak sign,
Air-Fluid Level Sign,
Halo sign,
CT
Halo sign, Burrow Sign of
Split-Pleura sign, Paragonimiasis sign
Crazy paving sign, Reverse Halo and Birds
Tree-in-bud sign, Nest Signs
Grape-Skin sign, Air fluid level sign
Air Crescent Sign
Consolidation
is an alveolar-filling process that replaces air within
the affected airspaces,increasing in pulmonary
attenuation and obscuring the margins of adjacent
airways and vessels on radiographs and CT scans
Air bronchogram sign
Bronchi, which are not normally seen,
become visible as a result of
opacification of the lung parenchyma.
This sign is most frequently
encountered in pneumonia and
pulmonary edema.
Example of air bronchogram sign.
Posteroanterior radiograph (lef) and coronal CT image (right)
show left lower lobe consolidation and air bronchogram sign (arrows).
Silhouette sign
The silhouette sign describes loss of a normal lungsoft-
tissue interface (loss of silhouette) caused by any
pathologic mechanism that replaces or displaces air within
the lung parenchyma.
This sign is commonly applied to the interface between the
lungs and the heart, mediastinum, chest wall, and
diaphragm.
Example of silhouette sign.
Posteroanterior radiographs show normal interface (right) and loss of
normal interface of lung and left-heart border (lef), thus localizing
abnormality to lingula.
Example of tree-in-bud
sign.
Photograph (top) shows
budding tree. Axial CT
image (bottom) shows
numerous V- and Y-
shaped tree-in-bud
opacities.
Bulging Fissure Sign
The bulging fissure sign represents expansive lobar
consolidation causing fissural bulging or
displacement by copious amounts of inflammatory
exudate within the affected parenchyma.
The sign is frequently seen in patients with
pneumococcal pneumonia
Fig. 575-year-old man with alcoholism and Klebsiella pneumonia. Example of bulging
fissure sign.
Posteroanterior (left) and lateral (right) radiographs show right upper lobe consolidation
causing inferior bulging of minor fissure (black arrows), posterior bulging of major
fissure (white arrow), and inferomedial
displacement of bronchus intermedius (asterisk).
Air Fluid Level Sign
Fig. 835-year-old man with Staphylococcus
B, Axial CT image shows
aureus pneumonia forming lung abscess.
parenchymal location of right lower
Example of air-fluid level sign.
lobe cavity with air-fluid level,
A, Posteroanterior (left) and lateral (right)
irregular internal contours, and
radiographs show right lower lobe cavity with air-
associated bronchus (arrow)
fluid level (arrows) of equal length on both
coursing to lesion.
orthogonal views. Thick, irregular
wall typical of lung abscess is evident.
Fig. 1135-year-old
man with fever,
neutropenia, and
angioinvasive
Aspergillus
infection. Example
of halo sign.
Posteroanterior
radiograph and axial
CT image
show right upper
lobe mass with
peripheral ground-
glass opacity
(arrows)
constituting halo
sign.
Fig. 1525-year-old woman with allergic bronchopulmonaryaspergillosis
(ABPA).Example of finger-in glove sign
Posteroanterior radiograph shows branching tubular opacities
(arrows) emanating from both hila.
Fig. 2427-year-old woman with
pulmonary hydatid
disease. Example of water lily sign.
Posteroanterior
radiograph shows large right lower
lobe thick-walled
cavity with lobulated airsoft-
tissue interface
representing floating endocyst
(arrow). Coronal
CT image (inset) from earlier
examination shows
unruptured cyst
CT
Crazy paving pattern
The crazy paving pattern consists of scattered or
diffuse ground-glass attenuation with
superimposed interlobular septal thickening and
intralobular lines . It was initially described in cases
of alveolar proteinosis .
In alveolar proteinosis, the ground-glass
attenuation reflects the low-density intraalveolar
material (glycoprotein), whereas the superimposed
reticular attenuation is due to infiltration of the
interstitium by inflammatory cells.
Figure a.Crazy Pavin in a
patient with Alveolar
proteinosis. b paving stone
CT scans show crazy-paving sign in patients with various disorders. Differential diagnostic
considerations are influenced by patients clinical presentation and disease course.
In patients with acute symptoms, crazy-paving sign may represent pulmonary edema,
pulmonary hemorrhage, or infection.
In patients with chronic symptoms, crazy-paving sign may represent lipoid pneumonia, lung
cancer, or pulmonary alveolar
Tree-in-bud sign
The tree-in-bud pattern is characterized by
small centrilobular nodules connected to
multiple branching linear structures of similar
caliber originating from a single stalk .
This pattern is a finding of small airways
disease. Initially, this sign was described in
cases with transbronchial spread of
Mycobacterium tuberculosis .
b

Figure 20. a, b. Tree-in-


bud pattern. a. Patient
with tuberculosis: small
centrilobular nodules
connected to multiple
branching linear
structures are seen. b.
Feeding vessel sign

The feeding vessel sign consists of a distinct vessel leading


directly to a nodule or a mass . This sign has been considered
highly suggestive of septic embolism and also frequently
occurs in pulmonary metastasis and arteriovenous fistula.
Example of feeding
vessel sign.
Coronal CT image shows
septic pulmonary emboli
manifesting themselves as
peripheral solid and
cavitary pulmonary
nodules of varying sizes.
Many nodules
exhibit feeding vessel sign
(arrows).
Split-Pleura Sign
Fig. 948-year-old woman with empyema. Example of split-pleura sign. 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. Adjacent atelectasis is
evident
in right lower lobe. Split-pleura sign is not specific for empyema but rather indicates
presence of exudative effusion. Chest tube is incompletely visible (black arrows).
Fig. 1955-year-old man
with chronic
coccidioidomycosis infection.
Example of grape-skin
sign. Posteroanterior
radiograph shows thin-walled
grape-skin cyst (arrows).
Axial CT image (inset)
shows that over time cavity
may deflate and acquire
slightly thicker wall
LANJUTAN
CT halo sign
The CT halo sign represents an area of ground-glass
attenuation surrounding a pulmonary nodule or mass on CT
images .
It is seen most commonly in the early stage of invasive
aspergillosis in immunocompromised patients.
Alveolar hemorrhage in aspergillosis and/or tumor infiltration
on the bronchial walls in bronchoalveolar carcinoma are
considered the causes of this sign.
a b

Figure a, b. CT halo
sign. a. Invasive
aspergillosis in a patient
with acute leukemia: CT
image shows halo sign
(arrows). b. Sunshine.
Split pleura sign
The split pleura sign is characterized by thickened pleural
layers separated by fluid . This sign is found primarily in
empyema, and it helps to differentiate from abscess.
Figure 22. Split pleura
sign. A patient with
empyema. Visceral and
parietal pleura are
thickened and separated
because of fluid.
Reversed halo sign
The reversed halo sign (atoll sign) is defined as a focal
round area of ground-glass attenuation and surrounding air-
space consolidation of crescent or ring shapes.
Kim et al. were the first to describe this particular CT feature
as the reversed halo sign
It is defined as a central ground glass opacity surrounded by
denser consolidation shaped like a crescent (forming more
than three quarters of a circle) or ring (forming a complete
circle) that is at least 2 mm in thickness. The reversed halo
sign seen on CT appears to be relatively specific to a
diagnosis of cryptogenic organizing pneumonia.
Voloudaki et al. reported that the central ground glass opacity
corresponds histopathologically to the area of alveolar septal
inflammation (inflammatory infiltrates in the alveolar septum
with macrophages, lymphocytes, plasmatic cells and some
giant cells, with a relative preservation of alveolar spaces) and
cellular debris and that the ring-shaped or crescentic peripheral
air-space consolidation corresponds to the area of organizing
pneumonia within the alveolar ducts
a b
Fig. 2144-year-old man with
febrile neutropenia and pulmonary
mucormycosis.
Example of reverse halo and birds
nest signs. Axial (left) and coronal
(right) CT
images show peripheral rim of
consolidation (arrows) surrounding
central groundglass
opacity, reticulation, and
nodularity. This appearance has
been likened
to birds nest and reverse halo.
Early diagnosis of mucormycosis
pneumonia is
imperative because standard
voriconazole therapy is not
effective for treatment.
(Courtesy of Chou S, University of
Washington, Seattle, WA)
Example of burrow sign. (Courtesy of Henry T, Emory University, Atlanta, GA)
A, Axial CT images in soft-tissue (lef) and lung (right) windows shows linear burrow track
(arrows) extending from thickened pleura to
pulmonary nodule.
B, Axial CT image shows long linear burrow track (arrow) in right upper lobe and small
pneumothorax.
PNEUMOTHORAX
Suatu keadaan dimana terdapatnya udara pada rongga
potensial diantara pleura viseralis dan pleura parietalis
(sharma et al, 2008
Figure. gambaran pada
pasien dengan
pneumotorak, tampak
adanya avascular pattern
pada paru kanan

https://radiopaedia.org/articles/pneumothorax
Figure.
gambaran pada
pasien yang
mengalami
tension
pneumotorax ,
terlihat adanya
paru yang
kolaps,
pergeseran
mediastinum

https://radiopaedia.org/articles/tension
EFUSI PLEURA
Suatu keadaan dimana terdapat penumpukan cairan dalam
rongga pleura
Figure. gambaran efusi
pleura unilateral terdapat
sudut kostofrenikus yang
menumpul

https://radiopaedia.org/articles/pleural-effusion
ATELEKTASIS
Pengkerutan sebagian atau seluruh paru-paru akibat
penyumbatan saluran udara (bronkus maupun bronkiolus) atau
akibat pernafasan yang sangat dangkal.
Figure.
gambaran dapa
pasien dengan
atelektasis lobus
bawah kiri

https://radiopaedia.org/articles/lung-

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