Viral pneumonia and respiratory sepsis: association, causation, or it depends? Photomicrograph (hematoxylin-eosin stain; original magnification, ×100) shows interstitial widening with formation of micronodules (arrows). No differences have been observed between the CT findings of immunocompromised and immunocompetent patients (9). 123, No. This infection occurs predominantly (46.7%) from June to September. Figure 5c. Viruses are classified on the basis of (a) the type and structure of the nucleic acid in the viral genome and the strategy used in its replication (eg, DNA or RNA), (b) the type of symmetry of the virus capsid (helical vs icosahedral), and (c) the presence or absence of a lipid envelope. The disease has spread rapidly since then, with 254 206 cases having been documented worldwide as of September 7, 2009, and an estimated 2837 deaths (88). Pneumonia due to influenza virus in a 21-year-old man with a cough. (b, c) Axial chest CT images obtained on the same day at the lower trachea level (b) and the interlobar area level (c) show multiple irregular areas of nodular tree-in-bud opacity and patchy consolidations (arrows) along the bronchovascular bundles and mild bronchial wall thickening. Adenovirus is a double-stranded DNA virus with more than 50 identified serotypes that account for 5%–10% of all respiratory tract infections in children (11). However, small nodules or ill-defined GGO and consolidation are typical features of CMV pneumonia, whereas apical distribution and homogeneous GGO are more frequently noted in patients with Pneumocystis carinii pneumonia (29). Figure 1b. Supplemental material:, After reading the article and taking the test, the reader will be able to. Frequency, severity, and duration of rhinovirus infections in asthmatic and non-asthmatic individuals: a longitudinal cohort study, Community respiratory virus infections in immunocompromised patients: hematopoietic stem cell and solid organ transplant recipients, and individuals with human immunodeficiency virus infection, Viral infection following kidney transplantation: long-term follow-up in a single center, Respiratory virus infections in stem cell transplant patients: the European experience, Respiratory viral infections in lung transplant recipients: radiologic findings with clinical correlation, Pulmonary infections after bone marrow transplantation: clinical and radiographic findings, Cytomegalovirus pneumonia in transplant recipients, Pulmonary complications and mortality after liver transplant, Medical complications of lung transplantation, Clinical implications of respiratory virus infections in solid organ transplant recipients: a prospective study, Post-operative nosocomial infections after lung and heart transplantation, Atypical and opportunistic pulmonary infections after cardiac surgery, Bacterial and fungal pneumonias after lung transplantation, Herpesviruses and the transplanted lung: looking at the air side, CMV-specific T-cell immunity, viral load, and clinical outcome in seropositive renal transplant recipients: a pilot study, Cytomegalovirus in transplantation—challenging the status quo, Pulmonary and blood stream infections in adult living donor and cadaveric liver transplant patients, Aspergillus pneumonia in renal transplant recipients, Respiratory syncytial virus infections in immunocompromised adults, Increasing incidence of adenovirus disease in bone marrow transplant recipients, Pulmonary infiltrates in non-HIV immunocompromised patients: a diagnostic approach using non-invasive and bronchoscopic procedures, Improved diagnosis of the etiology of community-acquired pneumonia with real-time polymerase chain reaction,, Open in Image Primary infection with EBV occurs early in life and manifests as infectious mononucleosis with the typical triad of fever, pharyngitis, and lymphadenopathy–which are often accompanied by splenomegaly (174). *Specimens for diagnostic test were respiratory samples (nasopharyngeal swab or aspirate, sputum, tracheal aspirate, or bronchoalveolar lavage fluid), unless otherwise stated. Figure 1c. Bats and dromedary camels are considered to be reservoirs of MERS coronavirus. (b) Pneumonia due to CMV shows diffuse ill-defined patchy GGO with interlobular septal thickening (arrowheads) in both lungs. In comparison, HMPV infection causes severe pneumonia with mortality of 10%–40% in hematopoietic stem cell transplant recipients, with a 5% incidence of infection. HTLV-1 is an etiologic retrovirus of adult T-cell leukemia or lymphoma (117,119). 94, No. A sample of 58 age-matched patients was randomly selected and evaluated by four radiologists from the United States in a similar fashion. At multidetector CT, the ground-glass opacities and areas of consolidation have a predominant peribronchovascular and subpleural distribution, resembling organizing pneumonia (91) (Fig 14). Most of those infected were previously healthy individuals. The epidemiology and pathogenesis of viral infections are discussed in Appendix E1 (online). On average, the radiologists proved capable of distinguishing COVID‑19 from other common viral pneumonia on chest CT with an accuracy of 82.1%, a specificity of 83.7%, and a sensitivity of 80.4%. Figure 10: Transverse thin-section CT scan through the lower lobes in a patient with adenovirus infection shows patchy bilateral ground-glass opacities with superimposed linear opacities (crazy-paving pattern) (arrows). Chest radiographs may be initially normal but progressively worsen, displaying signs of pulmonary edema and acute respiratory distress syndrome (125,126). (b) Frontal chest radiograph obtained 6 hours later demonstrates rapid progression to diffuse perihilar and lower lung consolidation, reflecting associated diffuse alveolar damage. • Viral pulmonary infections are clinically important in both immunocompromised and immunocompetent patients; despite its limitations, CT is currently the imaging modality of choice for the evaluation of pulmonary viral infections. Adenovirus infection exhibits more severe and fatal conditions with acute respiratory distress syndrome in immunocompromised patients. 7, No. Hantaviruses are transmitted by rodent vectors, while the others in Bunyaviridae are transmitted by arthropod vectors. (b–d) Axial CT images (3-mm section thickness) obtained on the same day at the level of the right inferior pulmonary vein (b) and the junction of the right atrium and inferior vena cava (c) and a coronal reconstruction image at the vertebral body level (d) show multifocal patchy and nodular consolidation with GGO (arrows) in both lower lobes. These investigators pointed out that the possibility of CMV pneumonia should be considered in patients with AIDS, particularly if they have Kaposi sarcoma and areas of dense consolidation or masslike opacities. On June 11, 2009, the World Health Organization declared the first pandemic of the 21st century caused by swine-origin influenza virus A (H1N1) (87). The probable predominant organism varies with the host’s epidemiologic factors, the severity of illness, and the laboratory approach used to establish the diagnosis. It is a known cause of life-threatening pneumonia in hematopoietic stem cell transplant recipients and those with hematologic malignancies. Mimics in chest disease: interstitial opacities, Infectious chest complications in haematological malignancies, Les complications infectieuses thoraciques des hémopathies malignes, Imaging pneumonia in immunocompetent and immunocompromised individuals, Computed Tomography Findings of Influenza A (H1N1) Pneumonia in Adults, Pneumonia and acute respiratory distress syndrome, The Wide Spectrum of Viral Pneumonias in Adults. The radiologic findings reflect the variable extent of the histopathologic features, which include diffuse alveolar damage (intraalveolar edema, fibrin, and variable cellular infiltrates with a hyaline membrane), intraalveolar hemorrhage, and interstitial (intrapulmonary or airway) inflammatory cell infiltration (20). Journal of Thoracic Imaging, Vol. For this journal-based CME activity, author disclosures are listed at the end of this article. 1, The Egyptian Journal of Radiology and Nuclear Medicine, Vol. Multifocal nodular infiltration represents infected areas of cells with cytoplasmic CMV inclusion. Lobar, segmental, or subsegmental atelectasis was present in seven patients. Information on COVID-19 for medical personnel in radiology department. Although hantavirus pulmonary syndrome and acute interstitial pneumonia can share similar clinical presentations, acute interstitial pneumonia and fatal cases of hantavirus pulmonary syndrome can generally be differentiated on clinical and histologic grounds, and this distinction can be further confirmed immunohistochemically (18). The important factor is progression of the lung changes and diffuse distribution in both lungs. Out of Mexico? Subjects and Methods . Recently, new viruses associated with recent outbreaks including human metapneumovirus, severe acute respiratory syndrome coronavirus, and Middle East respiratory syndrome coronavirus have been discovered. The RSNA is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. It resolves within several weeks or months without sequelae but may be accompanied by neurologic, hematologic, hepatic, respiratory, or psychologic complications (30). (d) Pneumonia due to influenza A virus shows multiple irregular areas of consolidation (arrows) along the bronchovascular bundles and diffuse GGO (arrowheads) with interlobular septal thickening in both lungs. In May 2015, a large outbreak of MERS coronavirus infection occurred in South Korea, with 186 identified patients and 38 deaths. Herein, emphasis was placed on the commonest imaging features of some of the most common viruses that produce pulmonary disease. In the study, children younger than 5 years were more prone to infection than were older children (37% vs 8%, respectively). 38, No. (a) Initial chest radiograph shows ill-defined patchy consolidation and GGO (arrows) in the left middle to lower lungs and the right lower lung zone. Although radiographic findings alone are not sufficient for the definitive diagnosis of viral pneumonia, in combination with clinical findings they can substantially improve the accuracy of diagnosis in this disease. Prolonged neutropenia is noted. SARS coronavirus was identified as a member of the family Coronaviridae in late 2003 after a world-wide epidemic. The thin-section CT appearances in varicella pneumonia largely reflect the multicentric hemorrhage and necrosis centered on airways (162). A thin-walled cyst is also visible in the right upper lobe (arrow). Presented as an education exhibit at the 2016 RSNA Annual Meeting. The imaging features of SARS-associated coronavirus infection consist of unilateral or bilateral ground-glass opacities, focal unilateral or bilateral areas of consolidation, or a mixture of both. (c, d) Follow-up axial chest CT images obtained 10 days later show an increased extent and intensity of lesions and increased irregular consolidation (arrows) along the bronchovascular bundles. HSV infection can show three forms of pulmonary involvement at pathologic evaluation: necrotizing tracheobronchitis, necrotizing pneumonia, or interstitial pneumonitis (21). (Images courtesy of Loren Ketai, MD, Albuquerque, NM.). Figure 26: Close-up view of transverse thin-section CT scan obtained with a multidetector unit in a young patient with tracheobronchial papillomatosis shows a small nodule (papilloma) arising from the tracheal wall (arrowhead). Scientists ponder swine flu’s origins, Pneumonia and respiratory failure from swine-origin influenza A (H1N1) in Mexico, Swine flu: after delays, WHO agrees—the 2009 pandemic has begun. Figure 4a. Figure 11b. Immunocompetent patients usually recover without risk of death (48). There was a good correlation between the size of the nodules and their origin. Figure 5: Histopathologic features of diffuse alveolar damage in a patient with SARS. (b, c) Axial thin-section (1-mm collimation) chest CT images obtained on the same day show irregular patchy consolidation (arrows) along the bronchovascular bundles and in peripheral areas of the lungs, bronchial wall thickening, and interlobular septal thickening (arrowhead), with a small amount of bilateral pleural effusion (*). 1, Current Opinion in Infectious Diseases, Vol. For non-COVID-19 viral pneumonia and ... for automatic detection of COVID-19 pneumonia lung CT volumes and have ... available at this time for this novel virus [1, 2]. Various histopathologic patterns of lung injury have been described in viral pneumonia. Figure 3c. Pneumonia due to rhinovirus in a 51-year-old man with acute myeloid leukemia who presented with dyspnea 3 months after bone marrow transplantation. CMV pneumonia is a major cause of morbidity and mortality following hematopoietic stem cell and solid organ transplantation and in patients with AIDS in whom CD4 cells are decreased to fewer than 100 cells per cubic millimeter. As with consolidation, a variety of acute and chronic lung diseases may result in lobular areas of ground-glass opacity, which give the lung a mosaic appearance. 1, 18 December 2012 | Insights into Imaging, Vol. Pleural effusion is common (16). Myelopathy, Sjögren syndrome, and lymphocytic pneumonitis have been reported in association with HTLV-1 infection (120). Radiologic findings are usually normal initially or consist of minimal interstitial edema. This complication characteristically occurs during the postengraftment period (30–100 days after transplantation), with a median onset time of 50–60 days after transplantation (165,166). Thin-section CT is an effective diagnostic method when findings at chest radiography are normal or inconclusive. Approximately 20% of all virus cases were identified in health care workers and persons who come into close contact with camels (76). (a) Pneumonia due to varicella-zoster virus shows multifocal 1–10-mm well-defined or ill-defined nodular opacity (arrows) with a surrounding halo or patchy GGO (arrowheads) in both lungs. The first goal of this review is to indicate that there are imaging features that should raise the possibility of viral infections. CT of common community-acquired viral lower respiratory tract infections (LRTIs) is still in its infancy, with only a few previously published studies comprising approximately 250 cases [1–19].However, to our knowledge, direct comparisons of the imaging features of the different viral causes of LRTI have not been performed. Virus detection may be performed by means of virus isolation or reverse transcriptase PCR (111). Image from scanning low-power microscopy (hematoxylin-eosin stain; original magnification, ×20) shows nodular zones of necrosis, some of which are bronchiolocentric (arrows). Oikonomou et al (65) reviewed the thin-section CT findings in four patients with hematologic malignancies and influenza A pneumonitis and found that the predominant thin-section CT findings were ground-glass opacities, consolidation, centrilobular nodules, and branching linear opacities (Fig 12). (b) Pneumonia due to CMV shows diffuse ill-defined patchy GGO with interlobular septal thickening (arrowheads) in both lungs. Influenza viruses are members of the Orthomyxoviridae family. The lesions may calcify, and well-defined scattered 2–3-mm hyperattenuating calcifications can persist (25). Although not all cases manifest with typical patterns, most typical imaging patterns of viral pneumonia can be classified according to viral families. Table 2: Pathogenesis and CT Findings of Viral Pneumonia. 9, No. 93, No. The article "Emerging Coronavirus 2019-nCoV Pneumonia" was published online Feb. 6. Prolonged neutropenia is noted. (a) Initial chest radiograph shows increased areas of ill-defined nodular opacity (arrows) in both lower lung zones, especially in the left retrocardiac area. CT: Unifocal GGO (arrow). Prolonged neutropenia is noted. The most common method is the demonstration of measles virus–specific IgM in a single serum sample, but a more than fourfold titer increase in paired serum samples is also formal proof of a recent measles virus infection. Antiviral therapy can reduce attack rates and decrease outbreaks and could reduce the public health burden. Herpes simplex virus type 1.—Herpes simplex virus type 1 pneumonia may be a life-threatening infection seen almost exclusively in immunocompromised and/or mechanically ventilated patients, usually as a component of polymicrobial infection (156). For example, RSV and HPIV replicate in the nasopharyngeal epithelium, spread to the lungs, and induce bronchiolitis with sloughing of epithelial cells of the small airways (6). 1, No. (d) Pneumonia due to influenza A virus shows multiple irregular areas of consolidation (arrows) along the bronchovascular bundles and diffuse GGO (arrowheads) with interlobular septal thickening in both lungs. Air trapping may be present because of associated bronchiolitis (Fig 11). (a) Initial chest radiograph shows multiple irregular nodular peribronchial air spaces or GGO (arrows) in both lungs and a small amount of bilateral pleural effusion. Human bocavirus also is detected frequently in adults with mild respiratory symptoms. Human papilloma viruses are known to cause recurrent papillomas and have been linked to lung cancer. Several antiviral drugs are currently available (Table 3). (c) Axial CT image obtained on the same day as b shows irregular consolidation (arrows) along the bronchovascular bundles and diffuse GGO with interlobular septal thickening (arrowheads) in both lungs. Early (30–100 days) after transplantation is the critical time for CMV infection, and CMV infection is a frequent complication of both hematopoietic stem cell transplantation and solid-organ transplantation. A recent prospective study of hospitalized children showed that human bocavirus is the fourth most commonly detected virus, with an incidence of 9.9%, followed by RSV (39.8%), rhinovirus (30.6%), and adenovirus (15%); 75% of bocavirus infections are coinfections with other viruses (35). In the specific context, coexisting inflammatory small airways and parenchyma disease may both contribute to a mosaic attenuation pattern (49). Thickened interlobular septa also are observed. Umans et al (157) reviewed the radiographic findings in 14 patients with herpes simplex virus pneumonia. ), Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, South Korea; and Department of Radiology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, South Korea (S.L. Unifocal involvement is more common than multifocal or bilateral involvement. In a study by Chang et al (146) of 19 children with postinfectious bronchiolitis obliterans, chest radiographs showed five patterns: (a) unilateral hyperlucency of increased volume, (b) complete collapse of the affected lobe, (c) unilateral hyperlucency of a small or normal-sized lung, (d) bilateral hyperlucent lungs, and (e) mixed pattern of persistent collapse and hyperlucent and peribronchial thickening. 42, No. Table 1 Summary of CT Findings in Viral Pneumonia. More than 40 hantavirus species are known, and greater than 20 of these are considered pathogenic in humans. The imaging findings of these emerging pathogens have been described in a few recent studies. Pneumonia due to MERS coronavirus in a 27-year-old man who presented with a cough and sputum. Adenovirus appears as multifocal consolidation or ground-glass opacity (GGO), and GGO was more frequently noticed in patients with adenovirus pneumonia than in those with other viral infections or bacterial infections. A worldwide outbreak of SARS coronavirus, which was first identified in Guangdong Province, China, occurred during 2002–2003. Figure 7: Transverse thin-section CT scan at the level of the bronchus intermedius in a patient with RSV infection shows a hazy increase in lung opacity without obscuration of underlying vessels. (a) Initial chest radiograph shows extensive patchy consolidation (arrows) with air bronchogram (arrowheads) in both lungs, especially in the middle to lower lung zones. Also, SARS coronavirus–encoded proteins induce cell apoptosis, including that of the lungs, kidneys, and liver. Influenza pneumonia is among the most common viral pneumonia, and now it is just during the “flu season”; therefore, it is essential to differentiate COVID-19 pneumonia from influenza. Although not all cases demonstrate typical imaging patterns, most viral pneumonia patterns exhibit similarity on the basis of viridae (Fig 1). 1, 12 November 2020 | Radiology: Cardiothoracic Imaging, Vol. Reverse transcriptase PCR is a modification of PCR used when the initial template is RNA rather than DNA. Further studies aimed at elucidating the imaging findings of newly identified viral pathogens, including human bocavirus and coronaviruses, could be of value for proper diagnosis and improvement of clinical outcomes. The CT signs of pulmonary viral infection will depend on the underlying pathologic process. (a) Initial chest radiograph shows extensive patchy consolidation (arrows) with air bronchogram (arrowheads) in both lungs, especially in the middle to lower lung zones. SARS was first detected in the Guangdong Province of China in late 2002, with major outbreaks in Hong Kong, Guangdong, Singapore, and Toronto and Vancouver, Canada (132). Enteroviruses account for most viruses recovered from children with summertime upper respiratory tract infections (112). (c, d) Follow-up axial chest CT images obtained 10 days later show an increased extent and intensity of lesions and increased irregular consolidation (arrows) along the bronchovascular bundles. The viruses usually appear as multifocal patchy consolidation with GGO, and centrilobular nodules with bronchial wall thickening are also noticed. 4, Journal of X-Ray Science and Technology, Vol. Figure 6b. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. Although definitive diagnosis cannot be made on the basis of imaging features alone, a combination of clinical and radiographic findings can substantially improve the accuracy of diagnosis in this disease. Although most patients had a mixed airspace and interstitial pattern of opacity, 11 showed at least an airspace consolidation. Histologically, CMV has four major patterns of lung involvement: (a) miliary pattern, (b) diffuse interstitial pneumonitis, (c) hemorrhagic pneumonia, and (d) CMV inclusions associated with minimal inflammation of lung injury. Figure 5a. Coxsackievirus B, reoviruses, and rhinoviruses may also infect the lungs, usually producing interstitial pneumonias with diffuse alveolar damage. Imaging and clinical manifestations of viral pneumonia are protean and not reliably predictive of its origin. 3, © 2021 Radiological Society of North America. The most common imaging finding of Avian flu is multifocal consolidation. However, in patients with AIDS, who have a more profound immune deficiency, it may be difficult to mount a serious immune response, and lung damage appears to be the direct result of the cytopathogenic effects of CMV, with a high density of CMV inclusion bodies and more severe and diffuse alveolar damage observed at histopathologic examination (27). 2, No. Pneumonia due to CMV in a 28-year-old man with graft-versus-host disease after bone marrow transplantation for chronic myeloblastic leukemia. 34, No. 9, No. Pleural effusions can also develop during the course of the disease (34,157,158). Figure 12d. Herein, we described and summarized the chest CT findings of 122 patients with COVID-19 pneumonia and 48 patients with influenza, and tried to explore the radiological … The diagnosis of varicella infection usually can be established on the basis of clinical findings (rash, pulmonary symptoms, and history of contact with a patient with chickenpox). Figure 2: Histopathologic features of respiratory syncytial virus (RSV) bronchiolitis in a child. (c, d) Follow-up axial chest CT images obtained 10 days later show an increased extent and intensity of lesions and increased irregular consolidation (arrows) along the bronchovascular bundles. Pneumonia due to MERS coronavirus in a 27-year-old man who presented with a cough and sputum. The “influenza” syndrome, which may be caused by viruses other than influenza, consists primarily of abrupt fever, headache, myalgias, and malaise. 2, 14 February 2020 | Radiology: Cardiothoracic Imaging, Vol. (a, b) Initial axial chest CT images at the main bronchial level (a) and the interlobar area level (b) show multifocal ill-defined nodular GGO lesions (arrows) along the bronchovascular bundles and mild bronchial wall thickening (arrowheads). However, masses and masslike infiltrates can be more common in patients with AIDS than in non-AIDS patients (28,29). An acute lung injury pattern may be present, with interstitial edema, congestion, and inflammation. Viewer,, Social Distancing with Portable Chest Radiographs During the COVID-19 Pandemic: Assessment of Radiograph Technique and Image Quality Obtained at 6 Feet and Through Glass, Review of the Chest CT Differential Diagnosis of Ground-Glass Opacities in the COVID Era, Chest CT in COVID-19: What the Radiologist Needs to Know, Coronavirus Disease 2019 (COVID-19): A Perspective from China, Time Course of Lung Changes at Chest CT during Recovery from Coronavirus Disease 2019 (COVID-19), Radiological Society of North America Expert Consensus Document on Reporting Chest CT Findings Related to COVID-19: Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA, Chest CT Severity Score: An Imaging Tool for Assessing Severe COVID-19, The Many Faces of COVID-19: Spectrum of Imaging Manifestations, Pulmonary measles disease: old and new imaging tools, Herpes Simplex Virus-1 qPCR in the Diagnosis of Lower Respiratory Tract Infections in Organ Transplant Recipients and Critically Ill Patients, Radiographic and CT Features of Viral Pneumonia, Diagnostic Imaging in Sepsis of Pulmonary Origin, Nasopharyngeal viral PCR in immunosuppressed patients and its association with virus detection in bronchoalveolar lavage by PCR, Viral Pneumonia in Patients with Hematologic Malignancy or Hematopoietic Stem Cell Transplantation, Thoracic Imaging Features of Legionnaire's Disease, H1N1 viral pneumonia: Spectrum of chest HRCT findings, Early chest computed tomography in adult acute severe community-acquired pneumonia patients treated in the intensive care unit. 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