Clinico Radiological Series

IMAGING OF CHEST INFECTIONS

Clinico Radiological Series

IMAGING OF CHEST INFECTIONS Editors Ashu Seith Bhalla

MD MAMS FICR

Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Manisha Jana

MD DNB FRCR

Associate Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Co-Editor Priyanka Naranje MD DNB MNAMS Assistant Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Clinical Contents Edited by Randeep Guleria

MD DM FAMS

Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

GC Khilnani

MD FCCP FAMS

Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

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Dedicated to Our “karambhoomi”—All India Institute of Medical Sciences, New Delhi, India

Contributors Abanti Das

Deepali Jain MD DNB FIAC

MBBS MD

Fellow in Thoracic Radiology Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Associate Professor Department of Pathology All India Institute of Medical Sciences New Delhi, India

Ajit Singh Oberoi

Gagandeep Singh

MBBS MS (Trainee)

MBBS MD

Resident Department of Surgical Disciplines All India Institute of Medical Sciences New Delhi, India

Assistant Professor Department of Microbiology All India Institute of Medical Sciences New Delhi, India

Anant Mohan

GC Khilnani

MD FRCP FCCP

MD FCCP FAMS

Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

Professor and Head Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

Ankur Goyal

Karan Madan

MD DNB MNAMS

Assistant Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Ashu Seith Bhalla

MD DM

Assistant Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

MD MAMS FICR

Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Chandrashekhara SH

Manisha Jana

MD DNB FRCR

Associate Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

MD DNB MNAMS

Associate Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Manjunath Bale

MBBS MS

Assistant Professor Department of Surgical Disciplines All India Institute of Medical Sciences New Delhi, India

Devasenathipathy Kandasamy MD DNB FRCR

Mukesh Yadav

Associate Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Assistant Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

MD

viii Clinico Radiological Series: Imaging of Chest Infections

Naveet Wig

Sarita Mohapatra

MD

Professor Department of Medicine All India Institute of Medical Sciences New Delhi, India

Poonam Sherwani

MD DNB

Fellow in Pediatric Radiology Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Priyanka Naranje

MBBS MD

Assistant Professor Department of Microbiology All India Institute of Medical Sciences New Delhi, India

Smita Manchanda

MD DNB MNAMS

Assistant Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

MD DNB MNAMS

Assistant Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Sudhakar Pipavath MD

Professor Department of Surgical Disciplines All India Institute of Medical Sciences New Delhi, India

Professor of Radiology Associate Professor of Cardiothoracic Imaging Adjunct Professor of Pulmonary, Critical Care, Sleep Medicine and Medicine University of Washington Seattle, Washington, USA

Rakesh Lodha

Sudheer Arava

Rajinder Parshad MS

MD

Professor Department of Pediatrics All India Institute of Medical Sciences New Delhi, India

Randeep Guleria

MD DM FAMS

Director All India Institute of Medical Sciences New Delhi, India Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

Ranjit Kumar

MBBS MD

Senior Resident Department of Pathology All India Institute of Medical Sciences New Delhi, India

Ravinder Kaur

MD

Professor Department of Radiodiagnosis Government Medical College and Hospital Chandigarh, India

MBBS MD

Associate Professor Department of Pathology All India Institute of Medical Sciences New Delhi, India

Surabhi Vyas

MD DNB MNAMS

Associate Professor Department of Radiodiagnosis All India Institute of Medical Sciences New Delhi, India

Sushil K Kabra

MD DNB

Professor Department of Pediatrics All India Institute of Medical Sciences New Delhi, India

Vijay Hadda

MD FCCP

Assistant Professor Department of Pulmonary Medicine and Sleep Disorders All India Institute of Medical Sciences New Delhi, India

Preface In clinical practice, chest infections are amongst the commonest cause of significant morbidity and at times, mortality. The varied spectrum of such infections range from general population being affected by community acquired pneumonia, to immunocompromised individuals secondary to HIV, solid organ or hematopoietic transplantations being affected by uncommon, opportunistic organisms. Isolation of organism causing particular infection is difficult in this era of antibiotic overuse and treating physician relies on imaging for possible etiological diagnosis. Imaging patterns on chest radiograph give important clues to the initial assessment of infections. Subsequent characterization on CT helps to detect the pattern and extent of involvement, complications or suggest alternative diagnosis. This book describes the role of imaging in diagnosis as well as image guided interventions at chest infections with reference to latest guidelines. There are certain common imaging patterns for infectious and non-infectious disease processes affecting the chest and given clinical context is of utmost importance to be able to distinguish between the two. The book tries to cover salient imaging differences between infections and their common non-infectious mimics. For the purpose of pattern assessment, there is separate section on ‘pattern wise approach on thoracic infections’. The variety of illustrative cases and proposed structured reporting formats for various scenarios are also provided at the end of the book. The ‘test yourself’ section is aimed at residents preparing for MD/DNB exams, senior residency or fellowship entrance exams and strategize to enhance learning. Apart from the residents, this book is aimed at practicing radiologists, physicians and pulmonologists managing the patients with chest infections. This book provides approach to diagnosis of chest infection, their complications as well as brief on the current management guidelines of infections and their complications, including radiological interventions. We welcome any feedback or suggestions on enhancing the content of the book, which can be incorporated in the subsequent editions. Ashu Seith Bhalla Manisha Jana

Acknowledgments We wish to thank all our contributors, for their efforts in compiling the text. We sincerely thank Prof Randeep Guleria for guiding us in this new endeavor. We are especially thankful to our radiology colleagues without the help of whom this effort would not have been easy. We are also grateful to our colleagues from the Department of Pulmonary Medicine and Sleep Disorders, Medicine, Surgery, Pathology and Microbiology; and also to faculty from other esteemed institutes for their contributions. We would also like to extend our appreciation to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President), Ms Chetna Malhotra Vohra (Associate Director–Content Strategy), Mr Subrata Adhikary (Commissioning Editor), Ms Moumita Ray Das (Development Editor), and all the staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for their efforts and input enabling timely publication of the book.

Contents SECTION 1: GENERAL 1. Imaging Techniques in Evaluation of Chest Infections

3

Devasenathipathy Kandasamy

2. Ultrasound in Chest Infections

12

Manisha Jana, Ashu Seith Bhalla

3. Microbiology of Pulmonary Infections

25

Sarita Mohapatra, Gagandeep Singh

4. Pathology of Lung Infections

36

Deepali Jain, Sudheer Arava, Ranjit Kumar

SECTION 2: IMAGING ACCORDING TO CAUSATIVE ORGANISM 5. Imaging of Bacterial Pneumonia

45

Smita Manchanda, Ravinder Kaur

6. Imaging of Viral Pneumonia

60

Devasenathipathy Kandasamy, Poonam Sherwani

7. Fungal Infections in Chest: Part 1

71

Priyanka Naranje, Vijay Hadda

8. Fungal Infections in Chest: Part 2

92

Priyanka Naranje, Ashu Seith Bhalla, Sudhakar Pipavath

9. Imaging of Parasitic Infections affecting the Chest

106

Ashu Seith Bhalla, Priyanka Naranje

10. Imaging in Chest Tuberculosis

124

Ravinder Kaur, Manisha Jana

11. Imaging of Nontuberculous Mycobacteria Pulmonary Infections Ashu Seith Bhalla, Smita Manchanda

146

xiv Clinico Radiological Series: Imaging of Chest Infections

SECTION 3: IMAGING ACCORDING TO CLINICAL SCENARIOS 12. Imaging of Community-acquired Pneumonia

159

Surabhi Vyas, Anant Mohan

13. Imaging of Hospital-acquired Pneumonia or Ventilator-acquired Pneumonia

173

Smita Manchanda, GC. Khilnani

14. Approach to Infections in Immunocompromised Host

183

Manisha Jana, Sushil K Kabra

15. Hematopoietic Stem Cell Transplantation: Imaging of Chest Infections

200

Mukesh Yadav, Chandrashekhara SH, Manisha Jana

16. Imaging of Pulmonary Infections Following Solid Organ Transplantation

218

Priyanka Naranje, Ashu Seith Bhalla

17. HIV-related Pulmonary Manifestations

238

Surabhi Vyas, Ashu Seith Bhalla, Naveet Wig

18. Imaging in Pediatric Lower Respiratory Tract Infections

254

Manisha Jana, Rakesh Lodha

19. Imaging Approach to Recurrent or Nonresolving Pneumonia

272

Ashu Seith Bhalla, Manisha Jana

SECTION 4: COMPLICATIONS OF PNEUMONIA 20. Complications of Chest Infections

291

Ashu Seith Bhalla, Surabhi Vyas, Karan Madan

21. Interventional Radiology in Chest Infections

312

Ankur Goyal, Ashu Seith Bhalla

22. Surgical Perspective for Evaluation and Treatment of Pulmonary Infections

331

Rajinder Parshad, Ajit Singh Oberoi, Manjunath Bale

SECTION 5: PATTERN-WISE APPROACH TO THORACIC INFECTIONS 23. Approach to Pneumonia and Consolidation

343

Smita Manchanda, Ashu Seith Bhalla

24. Approach to Nodules and Cavities in Suspected Chest Infection 364 Ankur Goyal, Ashu Seith Bhalla

Contents xv

25. Imaging of Infections of Pleura and Chest Wall

385

Priyanka Naranje, Randeep Guleria

26. Approach to Infections of the Mediastinum

404

Priyanka Naranje, Manisha Jana

27. Approach to Airway Infections

418

Priyanka Naranje, Abanti Das

SECTION 6: REPORTING FORMATS 28. Reporting Templates

435

Smita Manchanda, Ashu Seith Bhalla

29. Examination Section

454

Manisha Jana, Priyanka Naranje, Ashu Seith Bhalla

Index

471

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