Joseph Garland, HMS IV
Gillian Lieberman, MD
Round
Pneumonia
Joseph Garland, HMS IV
Gillian Lieberman, MD
Joseph Garland, HMS IV
Gillian Lieberman, MD
Case 1: Mr. H

Mr. H is a 45-year-old
man who presents with a
4 day history of full-body
myalgias, headaches and
fever to 103˚F. He also
complains of sharp leftsided chest pain worse on
deep inspiration.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Other Relevant Information





ROS: otherwise negative
PMH: asthma, one episode of pneumonia 6m
ago requiring hospitalization
SH: Nonsmoker, no IVDU, occasional EtOH.
PE: T=101.6˚F, HR=120. Crackles heard in
mid-lung field on the left. Otherwise wnl.
Labs: WBC 19.7, otherwise WNL.
Joseph Garland, HMS IV
Gillian Lieberman, MD
A chest X-ray was obtained…
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. H, Chest Radiographs
PACS, BIDMC
PACS, BIDMC
This was called a LLL pneumonia, cannot rule out infarct or malignancy. Do you agree?
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. H, Chest Radiographs – Magnification of Lesion
PACS, BIDMC
The lateral view suggests the mass is in the lingula.
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
The patient went on
to have a CT scan…Why?
Joseph Garland, HMS IV
Gillian Lieberman, MD
The Solitary Pulmonary Nodule
Has a lengthy differential…

Neoplastic (malignant or benign)







Bronchogenic carcinoma
Metastasis
Lymphoma
Carcinoid
Hamartoma
Connective tissue and neural
tumors - Fibroma, neurofibroma,
blastoma, sarcoma
Inflammatory (infectious)




Granuloma - TB, histoplasmosis,
coccidioidomycosis, blastomycosis,
cryptococcosis, nocardiosis
Lung abscess
Round pneumonia
Hydatid cyst

Inflammatory (noninfectious)





Congenital




Rheumatoid arthritis
Wegener granulomatosis
Sarcoidosis
Lipoid pneumonia
Arteriovenous malformation
Sequestration
Lung cyst
Miscellaneous




Pulmonary infarct
Round atelectasis
Mucoid impaction
Progressive massive fibrosis
Reference: Sharma S, Navaratnam S. “Solitary Pulmonary Nodule.” E-Medicine. 2004. http://www.emedicine.com
Joseph Garland, HMS IV
Gillian Lieberman, MD
In this case, we are most worried about differentiating
Pneumonia
(based on clinical presentation)
and
Bronchogenic carcinoma
(the most concerning possibility)
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr H, CT with IV contrast
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr H, CT with IV contrast
Inferior
lobar
bronchus
R intermediate
bronchus
Superior
division Lingular
bronchus
Major
fissure
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr H, Coronal CT with IV contrast
5.6 x 2.9 cm
peripheral
area of
consolidation
in the lingula
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Treatment started for CAP



Mr H was started on
Levofloxacin 500 mg PO
QD for clinical pneumonia.
His CXR and CT could not
rule out malignancy.
He clinically improved and
returned for a follow-up
Chest X-ray two months
later…
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. H, Follow-up Chest Radiographs (2 months later)
PACS, BIDMC
PACS, BIDMC
The lesion has resolved. The pleural thickening on the left is unchanged in 4 yrs.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Case 2: Mr. G.

Mr G is a 75 yo man who
presented to the
emergency department
with a fever to 104˚F and
chills x 1 day, and mild
shortness of breath.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Other Relevant Information





ROS: otherwise unremarkable
PMH: CAD s/p MI (1y ago), Hypertension,
permanent pacemaker
SH: 20 pack-year smoking history, quit 30y ago
PE: VS are stable, rest of exam is normal
Labs: WBC of 20.9, otherwise WNL
Joseph Garland, HMS IV
Gillian Lieberman, MD
As part of a fever workup,
a chest X-ray was obtained…
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. G, Chest Radiographs
2.5 m poorly-defined nodule
Left Upper Lobe
PACS, BIDMC
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
What should the next step be?



Clinical presentations suggestive
respiratory tract infection.
Chest radiograph findings are
atypical for (but not inconsistent
with) pneumonia.
Again, the major concern is “benign
vs malignant?”
Joseph Garland, HMS IV
Gillian Lieberman, MD
The patient went on
to have a CT scan…
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast
Tethering of the
major fissure
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr G, CT without contrast – Soft Tissue Window
Air bronchogram
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Findings



Findings may be consistent with round
pneumonia, but are suggestive of invasive
adenocarcinoma with bronchioloalveolar
component. Also consider post-obstructive
pneumonia.
Pt was started on Levofloxacin 500mg PO QD for
14 days.
He was scheduled for CT-guided biopsy but, after
clinical improvement, this was postponed.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. G, Follow-up Chest Radiographs (2 weeks later)
PACS, BIDMC
PACS, BIDMC
Joseph Garland, HMS IV
Gillian Lieberman, MD
Mr. G, Initial and Follow-up Chest Radiographs
Initial Presentation
2 weeks later, s/p antibiotics
PACS, BIDMC
PACS, BIDMC
Though still present, the nodule has partially resolved. A follow-up in 4w was recommended.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Round Pneumonia



First reported in the radiology literature in
1954 (though it was mentioned in the
surgical literature in 1940).
Describes any pneumonia presenting as a
nodule or “coin lesion”
It is rare, it accounts for less than 1% of
“coin lesions” of the lung
Joseph Garland, HMS IV
Gillian Lieberman, MD
Varied Clinical Presentations



Presentation may be with acute or
subacute symptoms of communityacquired pneumonia
Symptoms may also be mild, mimicking a
viral syndrome or bronchitis
Patients may even be completely
asymptomatic.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Radiologic Features



On Chest films: Rounded lesion. Air bronchograms may
be present. They are only present in 17% of patients with
round pneumonia and are not generally helpful because they
can also be seen in adenocarcinoma and bronchioloalveolar
carcinoma.
Recent Chest films are often helpful. 2-3cm masses that
appeared in the last 2-6 weeks are more likely infectious than
neoplastic.
On CT: heterogeneous mass of soft-tissue attenuation that
can have spicules, air bronchograms, pleural thickening
and satellite lesions.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Pediatric Round Pneumonia


Round pneumonia is more commonly a
disease of children. It is a diagnosis
considered in younger patients with classic
clinical picture of pneumonia and a coin
lesion on chest film.
Children rarely get a CT if the clinical
picture fits.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Pediatric case of Round Pneumonia
Courtesy Dr. Jason Handwerker, BIDMC
Courtesy Dr. Jason Handwerker, BIDMC
A typical presentation for this would be a very high fever in a child.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Theories on Formation



Round pneumonia may result from an infectious
focus that spreads centrifugally through the pores
of Kohn and canals of Lambert, or by destroying
the walls of alveoli.
However, children have underdeveloped pores of
Kohn and canals of Lambert, suggesting that in
children, the “roundness” may actually occur
because the lack of interalveolar pathways limits
the spread of the organism.
Round pneumonia may also represent incomplete
resolution of a lobar pneumonia.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Relevant Anatomy



Pores of Kohn:
openings in the alveolar
walls connecting
adjacent alveolar
lumens
Canals of Lambert:
connections between
terminal bronchioles and
adjacent alveoli
They allow for collateral
ventilation and also are
a means of bacterial
spread in the lungs.
Adapted from http://www.mevis.de/~hhj/Lunge/ima/InfKohnP.htm
Joseph Garland, HMS IV
Gillian Lieberman, MD
The Offending Agents


Usually Streptococcus pneumoniae
There are also reports of Klebsiella
pneumoniae, Mycobacterium tuberculosis,
and Coxiella burnetii (Q fever) presenting
with a round pneumonia.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Treatment


Standard treatment with antibiotics that
cover Strep. pneumoniae pneumonia
should suffice.
Always order a follow-up chest film to
document resolution of the lesion, and to
rule out a malignant process.
Joseph Garland, HMS IV
Gillian Lieberman, MD
When to Consider Round Pneumonia


Suspect round pneumonia in an adult patient who
present with a pulmonary mass, especially if s/he
has respiratory infection symptoms, is a young
nonsmoker, and has no other findings to suggest
malignancy. A recent normal chest radiograph is
also helpful.
Remember! Any patient with a pulmonary nodule
that does not decrease in size or resolution after
antibiotic treatment should be further assessed
with bronchoscopy or transthoracic needle biopsy.
Joseph Garland, HMS IV
Gillian Lieberman, MD
41-year-old female nonsmoker with fever and bibasilar rales.
Courtesy Dr. Andetta Hunsaker, BWH
Joseph Garland, HMS IV
Gillian Lieberman, MD
References












Ackerman LV, et al. 1954. “Localized Organizing Pneumonia: Its Resemblance to Carcinoma.” AJR.
71(6): 988-996.
Antón E. 2004. “A Frequent Error in Etiology of Round Pneumonia.” Chest. 125:1592-1593
Durning SJ, et al. 2003. “Pulmonary Mass in Tachypneic, Febrile Adult.” Chest. 124:372-375.
Greenfield H, Gyepes MT. 1964. “Oval-Shaped Consolidation Simulating New Growth of the Lung”
AJR. 91(1):125-129.
Lossos IS, Breuer R. 1989. “Round Pneumonia.” Isr J Med Sci. 25:713-714.
Fox LA, Hunsaker AR. 1997. “Localized Organizing (Round) Pneumonia.” BrighamRad.
http://brighamrad.harvard.edu/Cases/bwh/hcache/210/full.html
Price J. 1999. “Round Pneumonia and Focal Organizing Pneumonia are Different Entities.” AJR.
172:549.
Sharma S, Navaratnam S. 2004. “Solitary Pulmonary Nodule.” E-medicine.
http://www.emedicine.com
Wagner AL, et al. 1998. “Radiologic Manifestations of Round Pneumonia in Adults.” AJR. 170:723-726.
http://oac.med.jhmi.edu/Pathology/Idmicro/Bacteria/137B.html
http://www.mevis.de/~hhj/Lunge/ima/InfKohnP.htm
Beth Israel Deaconess Medical Center PACS system.
Joseph Garland, HMS IV
Gillian Lieberman, MD
Special Thanks





Dr. Maryellen Sun, BIDMC.
Dr. Phillip Boiselle, BIDMC.
Dr. Jason Handwerker, BIDMC.
Dr. Andetta Hunsaker, BWH.
Ms. Pamela Lepkowski, BIDMC.