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View Presentation - Society of Thoracic Radiology
Community Acquired Viral Pneumonia SUNDAY Tomas C. Franquet, MD ESTI SPEAKER Pulmonary Viral Infections Community Acquired Viral Pneumonia Background The lung is constantly exposed to different pathogens A significant cause of morbidity & mortality Globally, they are the second leading cause of death (following cardiovascular diseases) Imaging Diagnosis CXR is the first imaging examination in patients with suspected pulmonary infection Tomás Franquet MD. Hospital de Sant Pau. Barcelona CT is not a primary tool tool,, but is increasingly used to detect and characterize infiltrates Community Acquired Viral Pneumonia Community Acquired Viral Pneumonia Diagnostic criteria Diagnostic criteria Symptoms consistent with lung infection • Cough (> 90%); dyspnea (66%); sputum production (66%) and chest pain (50%) Objectives • To point out the role of imaging methods in the investigation of patients with suspected viral pulmonary infection New pulmonary infiltrate • To review the HRCT features and patterns associated with CommunityCommunity-acquired viral infection Acquired outside the hospital • To discuss some of the commonest organisms involved in CommunityCommunity-acquired viral infection Halm EA and Teirstein AS. N Engl J Med 2002 Key Clinical Questions Pulmonary Infections Role of Radiology Is there lung disease present ? Confirm or exclude presence of disease What is the nature of the disease ? Narrow differential considerations Is it infection ? What type of infection is it ? Is pathogen identification necessary ? Direct additional procedures Monitor followfollow-up 111 SUNDAY Key Clinical Questions Community Acquired Pneumonia Is it infection ? Diagnostic criteria • Pathogen is not idefined in > 50 % patients • S. pneumoniae is the leading cause of CAP • H. influenzae ( type yp B), ) S. aureus, aureus, and Differentiate lung infections from other conditions • In some situations may not be possible May suggest specific etiologies (TB, AIA) gram ((--) bacteria each account for 3 to 10 % • Respiratory viruses, 95% of cases of community-acquired viral pneumonia in communityimmunocompromised patients Serra MC et al. Eur Resp J 2008 Community Acquired Pneumonia Respiratory viruses in CAP Causative Pathogens Background 5,961 adults hospitalized with CAP in 26 prospective studies from 10 European countries > 55 million people die each year worldwide S. pneumoniae Pneumonia (3rd cause of death; 6.6%) C. pneumoniae Viral > 50% of cases without etiologic g diagnosis g Mycoplasma pneumoniae Legionella sp H influenzae High rate of viral infection in CAP (2 (2--35%) G-neg enterobacteria C. psittacii Better quality of diagnostic tests Coxiella burnetii Staph aureus Improvement in the ability to detect multiple viral pathogens M catarrhalis Other 0 5 10 15 20 25 30 Marcos MA et al. Curr Opin Infect Dis 2009; 22:143 22:143--147 Woodhead M. Chest 1998 Key Clinical Questions Key Clinical Questions Is it infection ? Infectious Pulmonary Nodules in the Immunocompromised Host Is it infection ? Infectious Pulmonary Nodules in the Immunocompromised Host Viral infection: None of viral nodules cavitated vs. 48.5% of nonnon-viral nodules ((P P < .0001) 83% of viral nodules had a ø < 10 mm (P (P < .0001) Only 5% of bacterial nodules had a ø < 10 mm 58.3% of viral nodules had “halo” (P < .0003) Multivariate analysis demonstrated that a ø < 10 mm was the only independent predictor of viral etiology of nodules (P (P < .0001) Absence of cavitation, < 10 mm ø & presence of “halo” Franquet T et al. JCAT 2003 112 &0 9 Nocardia asteroides SUNDAY 113 SUNDAY Human Influenza Virus Human Influenza Virus Bronchopneumonia HRCT Findings CT Peribronchovascular Disease, Lobular Ground Glass • Lobular GGO and consolidation • Centrilobular ill-defined nodules • Peribronchovascular disease Courtesy Kyung Soo Lee MD, Seoul Human Metapneumovirus (hMNV) Human Metapneumovirus (hMNV) Para ver esta película, debe disponer de QuickTime™ y de un descompresor TIFF (sin comprimir). 5 patients with HMPV infection after HSCT GGO (n=5) The Journal of Infectious Diseases 2002;186:1330–4 Consolidation (n=2) Nodules with “halo” (n=2) Nodules without “halo” (n=2) Current Opinion in Infectious Diseases 2003 “Tree-in-bud” (n=2) Air-trapping (n=2) Franquet et al JCAT 2005;29:223-227 Human Metapneumovirus 23/5/2004 30/5/2004 114 Human Metapneumovirus 23/5/2004 30/5/2004 10/6/2004 20/7/2004 10/6/2004 20/7/2004 Severe Acute Respiratory Syndrome (SARS) Severe Acute Respiratory Syndrome Severe Acute Respiratory Syndrome Radiography at Presentation CT Manifestations 80% of cases present with abnormal CxR > 50% of cases: focal focal, ill ill--defined, defined peripheral air space disease < than 50% of cases: bilateral illill-defined air space disease SUNDAY Severe Acute Respiratory Syndrome Findings in acute disease (first 2 wks) Ground glass opacity (GGO), consolidation • Relatively well defined • May be unilateral or bilateral Subpleural, often lower lungs Septal thickening Wong et al. Radiology 2003 Müller NL et al. AJR 2003 Severe Acute Respiratory Syndrome Severe Acute Respiratory Syndrome CT Manifestations CT Manifestations + 12 hours admissión 48 yo. male with SARS. 27 yo male with SARS Case from Nestor L. Müller. Vancouver General Hospital Case from Nestor L. Müller. Vancouver General Hospital 115 SUNDAY H5N1 Avian Influenza H5N1 Avian Influenza Hong Kong 1987 (18 Cases) • 3 yr. old boy contracts a LR infection & dies three days later • H5N1 serotype Influenza A isolated – Serotype had previously only been known to affect birds (e.g. ducks and chickens) • Fifteen additional cases occur – Fatality rate is 57% H5N1 Avian Influenza H5N1 Avian Influenza Viet Nam, Thailand, Cambodia, Turkey (2004-2006) Radiology • Total of 122 cases H5N1 influenza • Multifocal consolidation, at least two lobes • Mortality about 50% (62 deaths) – Effusions uncommon • Good News: News: Still no well documented reports of human to human transmission • Rapid progression to diffuse disease (6 days) • Bad News: News: • Airway disease (i.e. small nodules, airair-trapping, – Virus more pathogenic than 1997 strain bronchial wall thickening) not yet reported – Resistant to amantadine and rimantidine • Sensitive to Oseltamavir (Tamiflu®) Influenza A (H1N1) Virus “Swine flu” H5N1 – Viet Nam 2004 In April 2009, an outbreak of a human infection with a novel H1N1 influenza A virus was reported in Mexico Clinical manifestations: manifestations: cough, fever, sore throat, diarrhea, and nausea May 25, 2009: 43 countries, H1N1 Virus Courtesy F. Gleeson MD 116 with 12,515 reported cases and 91 associated deaths Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009; 360. Summary Hospital de Sant Pau SUNDAY Community Acquired & Viral Pneumonia Rx findings are variable and overlapping Some imaging findings are characteristic New pathogens are identified Integration of clinical features, imaging (HRCT), and microbiology is mandatory 117
