Pneumonia
Elisa Franquet, MD
Introduction
Pneumonia continues to be a signicant global health problem,
remaining among the top 10 causes of death globally and in the
US,1 especially among elderly patients.2 The diagnosis of
pneumonia relies mainly on clinical symptoms and imaging
ndings. Despite imaging studies playing an important role in
early diagnosis, laboratory conrmation can be obtained in only
30%-70% of cases even after a full microbial battery is
performed.3 Invasive procedures, such as bronchoscopy with
lavage and biopsy, are limited to hospital-associated infections
and immunocompromised patients.
Imaging Modalities
Chest radiography (CR) is considered the modality of choice for
detecting new inltrates in clinically suspected pneumonia.4,5
This modality provides information about localization, extent,
and prognosis, as well as excluding other causes of disease and
at times even suggesting an etiologic agent.5 However, the
specicity of CR is low, and interpretation agreement among
readers depends on their levels of expertise.6-8
In immunocompromised patients (including smokers and
diabetic patients), the appearance of signs of infection on CR
may be delayed. In neutropenic fever, for example, CR may
appear normal for up to 72 hours, though signs of underlying
pneumonia may be apparent on computed tomography (CT).
However, in patients who are immune competent, the early
stages of pneumonia are usually visible on CR within 12-24
hours.3,9,10 Therefore, the appropriate timing for obtaining CR
is crucial when diagnosing lung infections, particularly in
immunocompromised patients.
CT has higher sensitivity and specicity than CR and is
indicated when there is a strong suspicion of pneumonia with
normal or nonspecic CR (especially in immunosuppressed
hosts), failure of medical treatment in an immunocompetent
patient, recurrent pulmonary opacities, assessment of sus-
pected complications, or suspicion of an underlying obstruc-
tive lesion.9-12 CT is also superior in detecting associated
ndings, such as mediastinal lymphadenopathy in patients
Beth Israel Deaconess Medical Center, Boston, MA.
Address reprint requests to Elisa Franquet, MD, Beth Israel Deaconess Medical
Center, 330 Brookline Ave, Boston, MA 02215. E-mail: e.franquetelia@
gmail.com
http://dx.doi.org/10.1053/j.ro.2016.12.001
0037-198X/& 2017 Elsevier Inc. All rights reserved.
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with suspected tuberculosis (TB) and parenchymal abnormal-
ities in up to 50% of neutropenic patients with normal CR and
persistent fever refractory to empiric treatment.10,13-15 Never-
theless, CR is still the initial diagnostic imaging procedure
because of its widespread availability and its low cost and
radiation exposure.
The Different Faces of Pneumonia
The classic radiological patterns of pneumonia are lobar con-
solidation, bronchopneumonia, and interstitial consolidation.
The radiological ndings on CR and CT and the most common
organisms for each pattern are summarized in Table 1.10,16,17
The nodular pattern refers to the presence of multiple
rounded opacities (2-10 mm) in a widespread but not
necessarily uniform distribution.18 In an acute clinical setting,
centrilobular nodules of soft tissue attenuation are likely due to
infection. The most common cause is endobronchial spread of
bacterial, mycobacterial, or fungal organisms, and this appear-
ance represents an early manifestation of bronchopneumonia.
Centrilobular nodules of ground-glass opacity are more
characteristic of infections associated with a peribronchiolar
inammation without bronchiolar impaction, such as viral
(varicella zoster) and atypical bacterial (Chlamydia and Myco-
plasma pneumoniae) infections. The dilatation of centrilobular
bronchi lled with mucus, pus, or uid resembling a budding
tree (tree-in-bud pattern) is highly suspicious for infection
(especially bacterial and mycobacterial).18,19 Small nodules
(o2 mm in diameter) in a random distribution are highly
suggestive of miliary TB (Fig. 2), nontuberculous mycobac-
teria, or fungal infections (histoplasmosis, coccidioidomycosis,
cryptococcosis; Fig. 3).
Large nodules (41 cm) and cavities commonly reect an
infectious etiology, most likely septic embolism, bacterial lung
abscess, and fungal and mycobacterial infections. In the
immunocompromised host, Nocardia, Actinomyces, Mycobac-
teria, and Aspergillus frequently present as large nodules or
cavities or both. An air-uid level within a cavitary nodule or
mass suggests bacterial infection.
Immunocompetent Host
In general, approaching pneumonia from the host perspective
is clinically valuable, as each clinical setting has different
1
2 E. Franquet
Figure 1 Mycoplasma pneumoniae pneumonia. CT image shows a focal
consolidation in the lingula with air bronchogram (arrows).
associated comorbidities, risk of drug-resistance, treatment
approaches, and outcomes. The imaging presentation of
pneumonia tends to be different in these various situations.
Community-Acquired Pneumonia
Pneumonia acquired in the community setting, unrelated to a
hospital encounter, predominantly affects individuals at the
extremes of life3,20 and is a leading cause of hospitalizations,
particularly in elderly.2,21 Community-acquired pneumonia
(CAP) remains an important economic burden in the United
States despite the pneumococcal vaccine20,22 and the avail-
ability and adherence to treatment guidelines.23
Streptococcus pneumoniae is the most common pathogen
responsible for CAP (up to 40%),22 followed by Haemophilus
inuenzae, M. pneumoniae, Moraxella catarrhalis, Chlamydia,
and Legionella. Ps. aeruginosa can also cause CAP in patients
with chronic obstructive pulmonary disease (COPD) or
bronchiectasis, especially those undergoing steroid therapy.
During u outbreaks, inuenza virus becomes a major cause of
CAP and increases the risk of Staphylococcus aureus super-
infection.24 Other agents causing CAP are respiratory syncytial
virus and adenovirus. Non-TB Mycobacteria and fungi such as
Histoplasma and Coccidioides (endemic in the central and
southwestern parts of the United States) may cause subacute
pulmonary infections. An acute atypical pneumonia caused by
Coxiella burnetii is common in patients who have had contact
with animals. Nevertheless, the causative agent for CAP is only
found in 50% of cases.25-28
Lobar consolidation is the most frequent presentation of
CAP, with S. pneumoniae being the most common etiologic
micro-organism. Consolidation may be unilateral, bilateral,
and involve multiple lobes. Although small parapneumonic
pleural effusions are frequent, empyema is uncommon.29
Klebsiella also causes lobar consolidation (although is the
offending agent in o5% of cases of CAP).30 It commonly
affects mildly immunocompromised men in their 50s who are
chronic alcoholics, smokers, or diabetics.9,29 Klebsiella is an
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aggressive organism that presents as a rapidly progressive
exudative reaction leading to a lobar consolidation with
characteristic bulging ssures (heavy pneumonia).31 Margins
are sharp, and early abscess formation and cavitation often is
observed.9,11,32
Although frequent in children, round pneumonia is an
uncommon presentation of CAP in adults, with S. pneumoniae
the most frequent causative organism. It morphologically
presents as a round or oval consolidation (coin lesion) of
variable size, which is thought to be due to centrifugal spread
of infection. Radiographically, round pneumonia is most
commonly located in the lower lobes and typically presents
with smooth or mildly irregular margins (Fig. 4), although
lobulations and spicules may occur.33 On CT, round pneumo-
nia appears as a heterogeneous mass of soft tissue attenuation
that may be associated with coarse spicules, air bronchograms,
pleural thickening, and satellite lesions.33,34 Therefore, a
solitary pulmonary nodule with rapid growth (over 2-6 weeks)
and signs of infection should raise the possibility of round
pneumonia.35
Legionella pneumophila pneumonia is a rapidly progressive
and often fatal lung infection that commonly presents as
unilateral or bilateral, segmental peripheral opacications that
may rapidly enlarge and spread to additional lobes. On CT,
consolidations with associated areas of GGO are frequently
observed.36
Bronchopneumonia is most commonly caused by H.
inuenzae and S. aureus, with anaerobes and S. pneumoniae
less likely. H. inuenzae infections usually have a seasonal
variation, being most common in winter and spring. S. aureus,
which is found on the skin or nasopharyngeal mucosa in 20%-
30% of the population, leads to pyogenic exudates and lung
abscesses, which may be complicated by pleural effusion,
empyema, and pneumatocele formation.
M. pneumoniae, often coexisting with Chlamydophila pneu-
moniae, and viruses present as diffuse bilateral interstitial or
mixed interstitial-alveolar inltrates (Fig. 5).
Pulmonary nodules or masses (with or without cavitation)
are often caused by bacteria such as Legionella, C. burnetii, and
M. tuberculosis. In patients with COPD, cavitation is most
commonly associated with Mycobacterium tuberculosis, Asper-
gillus species, gram-negative bacilli, and S. aureus.
Hospital-Acquired Pneumonia
Hospital-acquired pneumonia (HAP), which develops at least
48 hours after admission, is the leading cause of mortality due
to hospital-acquired infections. Patients in the intensive care
unit and those with mechanical ventilation (ventilator-associ-
ated pneumonia) are more susceptible. HAP is usually
acquired by aspiration or inhalation of micro-organisms, by
direct implantation into the respiratory tract (by devices such
as bronchoscopy), or through hematogenous spread (endo-
carditis or septic emboli).
Although the most common pathogens in HAP are gram-
negative bacilli and S. aureus, pathogens such as S. pneumoniae,
M. catarrhalis, and H. inuenzae also can be involved. Enter-
obactericeae species, such as Escherichia coli and Klebsiella, are
Pneumonia 3

Table Patterns of Pneumonia and Their Causes

Lobar/alveolar consolidation Bronchopneumonia Interstitial pattern
Target Air-space Airways (bronchitis or bronchiolitis Interstitium
or both)

Spread Alveoli through the pores of Kohn and Along the airway walls and into Septal interstitium
channels of Lambert in the alveolar adjacent alveoli (causes ulcers in the
walls until it reaches the ssures walls and bropurulent membrane
(lls space) formation)

Limits Fissures No limits No limits

Radiograph Opacity Patchy, inhomogeneous Reticular, reticulonodular opacities

consolidation or nodular, patchy, alveolar
densities, and areas of ground-
glass opacities

Findings Begins peripherally and spreads Lobular, subsegmental, segmental Diffuse and bilateral
centrally
Nonsegmental, sublobar or lobar Usually multilobar and bilateral
Can be multilobar Air bronchogram usually absent
Air bronchogram may be present
(Fig. 1)
Silhouette sign

CT ndings Opacication with attenuation equal Centrilobulillar nodules Ground-glass opacities

to the vessels and airways Tree-in-bud opacities Septal thickening
(hampering the visualization of Bronchial wall thickening
such structures)
Ground-glass opacities Airway impaction and dilatation
Pleural extension
CT angiogram sign (opacied vessels
within the consolidation after the
infusion of IV contrast)

Most frequent S. pneumoniae Pseudomonas aeruginosa M. pneumoniae

organisms K. pneumoniae S. aureus Virus
Legionella Escherichia coli Mycobacterium tuberculosis
Moraxella catarrhalis Anaerobes Haemophilus inuenzae
Haemophilus inuenzae C. pneumoniae
PCP

the most common micro-organisms after 5 days of hospital

Figure 2 Miliary tuberculosis. CT image at the level of the aortic arch
shows numerous randomly distributed nodules, 1-2 mm in diameter,
throughout both lungs (miliary pattern).
admission.4,9,11,28,35,37,38
The diagnosis of HAP is challenging because of lack of classic
symptoms, difculties in identifying a causative agent, and a
high rate of associated acute respiratory distress syndrome.9
The radiographic ndings usually appear during the rst 12-
16 hours following the onset of clinical symptoms. Thus, the
acquisition of CR soon after the onset of symptoms often
results in a falsely normal appearance.39 CT should be
considered if there is a strong suspicion of pneumonia.12,13,15
Bronchopneumonia is the most frequent presentation of
HAP.9 Although uncommon, air bronchograms and air-space
consolidation abutting a ssure are the most specic signs.
Ps. aeruginosa infection should be considered in patients
with COPD, as well as those who have received corticosteroids

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4 E. Franquet
Figure 3 Cryptococcal pneumonia in a 50-year-old immunosup-
pressed male after hematopoietic stem cell transplant (HSCT).
Magnied PA chest radiograph shows multiple poorly dened small
nodules in the right upper lobe (multinodular pattern). PA,
posteroanterior.
or broad-spectrum antibiotics, had a prolonged stay in the
intensive care unit, or show bronchiectasis. This possibly fatal
pneumonia is a cause of chronic airways colonization in
patients with cystic brosis. Radiologically, it presents as
bronchopneumonia that predominantly involves the lower
lobes. Less frequently, it produces lobar consolidation (at times
with a bulging ssure), multiple nodular opacities, or a
reticular pattern. Complications include cavitation, pneuma-
tocele, unilateral or bilateral pleural effusion, and empyema.
Aspiration Pneumonia
The major complication of aspiration is pulmonary infection.
Aspiration can lead to the development of lobar or segmental
pneumonia, bronchopneumonia, lung abscess, and empyema.
The posterior segment of the upper lobes and the superior
segment of the lower lobes are the most commonly involved
sites.40 Aspiration pneumonia occurs more often in patients
with loss of consciousness, chronic debilitating disease,
Figure 4 Chest radiograph shows a 6-cm diameter rounded consolida-
tion with ill-dened margins in the right lung (round pneumonia).
The patient was a 55-year-old woman.
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Figure 5 Streptococcus pneumoniae pneumonia. CT image shows
multifocal ill-dened areas of mixed interstitial-alveolar inltrates.
There is lobular consolidation seen in the right upper lobe and a
segmental ground-glass opacity in the superior segment of the left
lower lobe.
structural abnormalities of the pharynx and esophagus, neuro-
muscular disorders, deglutition abnormalities, general anes-
thesia, and oropharyngeal or airway instrumentation.41
Alcoholism is probably the most important predisposing factor
for pulmonary aspiration in adults.40 Anaerobic organisms are
the offending pathogens in 90% of cases of aspiration
pneumonia.
The typical CR nding in aspiration pneumonia is bilateral,
multicentric segmental opacities that are most common on the
right, in the perihilar regions, and in the dependent portions of
the lung, with the location depending on the position of the
patient when the aspiration occurred (Fig. 6). The radiographic
manifestations vary with the organism involved. Ps. aeruginosa
infection typically results in bronchopneumonia, with lobar
consolidation less common. Cavitation suggests S. aureus,
gram-negative bacilli, anaerobes, or actinomycosis.
Actinomyces israelii is a common anaerobic bacterium of low
virulence found in patients with poor oral hygiene, periodontal
disease, and excessive alcoholic intake. Aspiration of this
organism produces a subacute localized or segmental pneumo-
nia that, if untreated, can result in cavitation, pleural effusion,
Figure 6 Aspiration bronchopneumonia. PA chest radiograph shows
bilateral ill-dened, patchy areas of consolidation in the lower lobes.
PA, posteroanterior.
Pneumonia
or empyema. The infection may invade the chest wall,
mediastinum, or diaphragm.10
Immunocompromised Host and
AIDS
The number of immunocompromised patients has increased
considerably in the past 3 decades because of 3 main
phenomena: the AIDS epidemic, advances in cancer chemo-
therapy, and expanding solid organ and hematopoietic stem
cell transplantation (HSCT).
In symptomatic patients, it is important to determine
whether the cause of symptoms is infectious or noninfectious.
The American Thoracic Society (ATS) guidelines recommend
that when possible posteroanterior and lateral chest radio-
graphs be obtained whenever pneumonia is suspected in
adults. CR must be routinely undertaken in patients with
presumptive pneumonia to make the diagnosis. However, a
normal chest radiograph should not exclude the diagnosis of
pneumonia, because the radiograph can lag behind the clinical
ndings by several days. CT is a useful adjunct to CR in
unresolved cases or when complications of pneumonia are
suspected.
In solid organ transplantation, bacterial pneumonia is the
most common respiratory infectious complication; cytomega-
lovirus (CMV) infection usually occurs within the rst
3 months after transplantation.42
Pulmonary complications following HSCT are common,
occurring in about half the number of patients. In the early
phase, bacterial infections are responsible for 90% of infections.
The most likely presentations are consolidation (S. pneumoniae,
Klebsiella) and bronchopneumonia (gram-negative bacteria,
S. aureus).
Fungi (mainly Aspergillus species) are the most frequent
cause of pulmonary infection during the neutropenic phase
(up to 3 weeks after transplantation), whereas CMV pneumo-
nia typically occurs 3 weeks to 100 days after transplanta-
tion.11,32,41,43-45
The characteristic CT ndings of angioinvasive aspergillosis
are air-space nodules (6-10 mm in diameter) and, less fre-
quently, segmental consolidation or bronchopneumonia. In
some cases, nodules may be associated with a halo of ground-
glass attenuation. In severely neutropenic patients, the halo
sign is highly suggestive of angioinvasive aspergillosis11,46,47
(Fig. 7). However, a similar appearance has been described in
infections due to nontuberculous Mycobacteria, Mucorales,
Candida, Herpes simplex virus, and CMV.48 The reversed halo
signa focal rounded area of ground-glass opacity sur-
rounded by a more or less complete ring of consolidation
is much less common and associated with mucormycosis.13
Both signs usually appear early during the course of infection.
Following treatment, the nodules may cavitate. Eccentric
cavitation produces the crescent sign, which has a good
prognosis. In mildly immunocompromised hosts (diabetics,
alcoholics, and those with COPD), aspergillosis presents as
lobar consolidation (semi-invasive form). Diabetics are
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5
Figure 7 Angioinvasive aspergillosis. CT image in a 30-year-old
neutropenic man shows a nodule in the posterior segment of the
right upper lobe surrounded by a halo of ground-glass opacity
(halo sign) (arrow).
especially at high risk for developing mucormycosis that tends
to cross ssures or invade the chest wall and pulmonary
arteries.
CMV pneumonia on CT produces solitary or multiple areas
of ground-glass attenuation, multiple small nodules sur-
rounded by a halo of ground-glass attenuation, and areas of
consolidation.
Pneumocystis jiroveci (formerly Pneumocystis carinii) is a
unique opportunistic fungal pathogen that causes pneumonia
in immunocompromised individuals, such as patients with
AIDS, organ transplants, or hematologic or solid organ
malignancies who are undergoing chemotherapy, and in
patients receiving immune-suppressive treatments, particularly
systemic corticosteroids. PCP is relatively rare among HSCT
patients, except in the setting of chronic graft-vs-host disease in
the late phase following allogenic transplantation.45 The
classical imaging ndings consist of extensive bilateral
ground-glass opacities that typically involve the perihiliar
regions or the middle and lower lungs10,29 (Fig. 8).
Other common organisms causing pulmonary infection in
this group are gram-positive and gram-negative bacteria, M.
tuberculosis, and Mycobacterium Avium Complex (MAC). Cryp-
tococcus and CMV are rarely seen in immunocompetent hosts,
but they are often encountered in patients with AIDS. In the
absence of symptoms, PCP or TB is most likely, and CT is the
recommended imaging modality.
Bacterial pneumonia and pyogenic bronchitis are the
most common manifestations of pulmonary infection in
patients with AIDS and are usually caused by S. pneumo-
niae, H. inuenzae, Ps. aeruginosa, and S. aureus. As in
immunocompetent hosts, lobar consolidation is the typ-
ical presentation of bacterial CAP in patients with AIDS.
Unilateral or bilateral bronchopneumonia are usually
caused by Ps. aeruginosa, Staphylococcus, Klebsiella, Enter-
obacter, or Haemophilus infection.
In AIDS, opportunistic lung infections usually occur in
patients with CD4 counts less than 200 cell/mm3; typical
6 E. Franquet

Figure 8 Close-up view of a high-resolution CT at the level of the carina

shows patchy ground-glass opacities in the right upper lung. Note
associated interstitial emphysema (thick arrow) and pneumomedias-
tinum (thin arrows).

bacterial pneumonia is more common when the CD4 count is

more than 500 cell/mm3. In the last decade, the prevalence of
opportunistic infections has decreased with the introduction of
highly active retroviral therapy (HAART).
The immunosuppressed state associated with AIDS predis-
poses to the reactivation of latent TB. MAC infection occurs in
advanced stages of AIDS, when the CD4 count is lower than
50 cells/mm3. The radiological ndings of TB are similar in
both immunocompromised and immunocompetent patients,
although mediastinal lymph node and bronchogenic spread
more frequently are seen in patients with HIV.49 The character-
istic CT ndings consist of focal areas of consolidation,
centrilobular nodules, and tree-in-bud opacities, mainly in
the apical and posterior segments of the upper lobes. Other
associated ndings are bronchovascular distortion secondary
to parenchymal destruction, cavitation, lymphadenopathy,
and pleural effusion. In patients with severe lymphocytopenia,
the ndings are similar to those in primary infection, including
focal, patchy, or mass-like heterogeneous consolidation in any
lobe, poorly dened nodules, and linear opacities. Unilateral
hilar or mediastinal lymphadenopathy or both can develop
with lymphatic spread of the disease. The impaired lympho-
cytic response in patients with AIDS prevents granuloma
formation, resulting in a higher rate of miliary TB than in
normal hosts.
Septic emboli caused by recurrent Staphylococcus infection
are most likely encountered among intravenous drug abusers
and present as multiple cavitary nodules on CT.
Figure 9 Pneumocystis jirovecii pneumonia. Magnied PA chest radio-
graph in a 33-year-old man with AIDS shows a left upper lobe
consolidation with an air-uid level (arrows). PA, posteroanterior.
made with certainty on radiologic grounds, but it may be
possible on CT.50 In a patient with pneumonia, the CT
demonstration of pleural thickening associated with a pleural
effusion and enhancement of both pleural layers after IV
contrast (split pleura sign) indicates the presence of an
exudative effusion or empyema.50,51
Aspiration can lead to the development of lobar or
segmental pneumonia, bronchopneumonia, lung abscess,
and empyema. Therefore, the posterior segment of the upper
lobes and the superior segment of the lower lobes are the most
commonly involved lung sites in aspiration disease.
Lung abscess, a necrotic cavitary lesion 42 cm in diameter
and containing pus, is most often related to S. aureus, gram-
negative anaerobic bacteria, and fungi. On CT, it typically
presents as a cavity (purulent necrosis), particularly in gravity-
dependent sites of the lung, with thickened walls, peripheral

Common Complications of
Pneumonia
Parapneumonic effusion, often unilateral, is a common pul-
monary complication in the setting of bacterial pneumonia. Figure 10 Lung abscess. Enhanced CT image (same patient as in Fig. 9)
Progression to empyema occurs in 5%-10% of cases. Dis- conrms a large abscess in the superior segment of the left lower lobe,
tinction of pleural transudate from pleural exudate cannot be with thick nodular walls and an air-uid level (arrow).

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Pneumonia
Figure 11 P. Jiroveci pneumonia in a 36-year-old HIV-positive male.
Coronal CT image shows bilateral ground-glass opacities containing
multiple cysts (pneumatoceles) (arrows).
contrast enhancement, and sometimes an air-uid level
(Figs. 9 and 10).
Necrotizing pneumonia (NP) may result as a sequela of
severe CAP or TB. Common causes include S. pneumoniae,
H. inuenzae, and several gram-negative anaerobes. Radio-
graphically, NP begins as a lobar consolidation, usually in the
upper lobes, followed by development of lucencies that
coalesce to form a cavity secondary to thrombosis of the
pulmonary vessels. NP should be suspected in all severely ill
patients with prolonged fever and signicantly elevated serum
inammatory markers. Although not always necessary, CT
may play an important role in showing necrotizing or cavitary
lesions that are not visible on CR. NP is associated with a very
high risk of local complications, such as empyema.
Pneumatoceles manifest as single or multiple, thin-walled,
air-cystic spaces within an area of consolidation, which usually
increase in size over days or weeks (Fig. 11). Pneumatoceles
occur most commonly in S. aureus and P. jiroveci pneumonia,
but they also may occur in infections due to E. coli and
S. pneumoniae.52-54 Pneumothorax is a common complication,
which occurs secondary to a ruptured pneumatocele or
extension of an air-lled lung abscess into the pleura (Fig. 8).
Differential Diagnosis
Unfortunately, the clinical data and radiographic ndings often
fail to lead to a denitive diagnosis of pneumonia, because
there are many noninfectious processes associated with febrile
pneumonitis. Pulmonary edema and the acute respiratory
distress syndrome are the most common conditions that
must be distinguished from bronchopneumonia when a
generalized pulmonary abnormality is demonstrated radiogra-
phically. Localized pulmonary disease with a lobar or
segmental distribution can be produced by bronchogenic
carcinoma, lymphoma, pulmonary infarction, and vasculitis.
Noninfectious inammation can also be related to adverse
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7
drug reactions, cryptogenic organizing pneumonia, eosino-
philic pneumonia, and nonspecic interstitial pneumonia.
All suspected pneumonias must be followed with CR after
4 weeks to evaluate for clearing of the process. However, it is
important to remember that resolution of a pneumonia often
lags behind clinical improvement and might take up to 6 weeks
to resolve on CR. Failure of antibiotic therapy to completely
clear a pulmonary consolidation should suggest an alternative
diagnosis.
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