Radiology of

Bacterial CAP
DR. Justinus Frans Palilingan, dr., Sp.P(K)
Diagnosis of pneumonia requires a combination of
Clinical assessment, Radiological imaging, and
appropriate Microbiological tests.

Plain Chest radiography is an inexpensive test and

is an important initial examination in all patients
suspected of pneumonia.

Computed tomography (CT) is a valuable adjunct in

negative or nondiagnostic chest radiography,
unresolved pneumonias, and when complications
are suspected.
Infection of the lower respiratory tract, acquired through the
airways and confined to the lung parenchyma and airways,
can present radiologically as one of three patterns:
(1) focal nonsegmental or Lobar pneumonia,
(2) multifocal Bronchopneumonia or lobular pneumonia, and
(3) focal or diffuse Interstitial pneumonia.

These patterns can be useful in identifying the causative

organism in the appropriate clinical setting. To serve the
purpose of this discussion, these patterns are used as the
primary method of classification of pulmonary infections
caused by different organisms.
Pathologically, Lobar pneumonia is a result of the
rapid production of edema fluid with relatively
minimal cellular reaction, occurring initially and
primarily in the periphery of the lung, then spreading
from acinus to acinus through the pores of Kohn
and canals of Lambert.

The infection is limited only by pleural boundaries

and eventually by the host's cellular reaction. The
quintessential lobar pneumonia occurs from
infection with Streptococcus pneumoniae.
 Lobar pneumonia
• Streptococcus pneumoniae
• Klebsiella pneumoniae
• Legionella pneumophila
• Others (aerobic gram-negative bacilli, M.
pneumoniae, H. influenzae, S. aureus, SARS,
Avian Influenza)
 Pneumococcal pneumonia
Lingular and right upper lobe
consolidation
Homogenous air space opacification of the left
lower lobe (complete lobar consolidation)
due to Streptococcus pneumoniae
Pneumococcal pneumonia
Round pneumonia
(S. pneumoniae)
Klebsiella pneumonia (PA)
Klebsiella pneumonia
(lateral view)
 Klebsiella pneumonia
A large cavity in the right lower lobe
 Klebsiella pneumonia
A large cavity in the right lower lobe
Legionella pneumonia
Legionella pneumophila pneumonia
causing lobar enlargement
(bulging minor fissure)
Legionella pneumophila pneumonia
causing lobar enlargement
(bulging minor fissure)
Legionnaire’s disease
Bilateral consolidation
SARS
SARS
AVIAN INFLUENZA
AVIAN INFLUENZA
 Bronchopneumonia
Pathologically, bronchopneumonia infections are
centered on large inflamed airways with patchy
involvement and a subsequent patchy appearance.
With the progression of disease, inflamed areas can
coalesce, giving rise to a lobar pattern of
involvement. Typically, there is an absence of air
bronchograms. Because of the destructive nature of
the causative organisms that produce this pattern,
abscess formation, pneumatocele, and pulmonary
gangrene are found commonly. Staphylococcus
aureus is a prototypical pathogen causing a
radiographic bronchopneumonia pattern.
 Bronchopneumonia
• S. aureus
• S. pyogenes
• P. aeruginosa
• H. influenza
• Anaerobic bacteria (aspiration pneumonia)
• M. catarrhalis
• E. coli
Staphylococcal pneumonia
with abscess formation
 Staphylococcal bronchopneumonia
A pneumatocele in the right upper lobe
 Haemophylus pneumonia
Widespread small nodular opacities
 Interstitial pneumonia
M. pneumoniae, C. pneumonia, and viral pneumonias typically
present as an Interstitial pneumonia.

The chest radiograph demonstrates accentuated bronchovascular

markings and reticular or reticulonodular opacities. The involved region
usually does not extend beyond one lobe but the interstitial pneumonia
may be diffusely distributed and may progress to a bronchopneumonia
pattern. An interstitial pattern can be seen in disseminated fungal and
mycobacterial infections. Other bacterial infections may present as an
interstitial pneumonia. This is especially true of S. pneumoniae in HIV-
infected patients.

Pneumocystis pneumonia (PCP) primarily involves the alveoli but

is usually first seen on the chest radiograph as diffuse bilateral interstitial
reticular or reticulonodular opacities. If unchecked the opacities typically
progress to regions of air space consolidation that may contain air
bronchograms.
 Mycoplasma pneumonia
A patch of left lung consolidation
 Adenovirus chest Infection
Reticulonodullaire, most marked in a
bronchovascular distribution at the right
base
 CMV pneumonia
Reticular nodular shadowing throughout both lungs
 Chickenpox pneumonia
Widespread predominantly nodular
shadowing throughout both lungs
 Measles giant cell pneumonia
Extensive ill-defined opoacities
with air bronchograms
PCP