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Mycoplasma pneumoniae Pneumonia

Radiographic and High-Resolution CT Features in 28 Patients

¹ Department of Radiology, Vancouver Hospital and Health Sciences Centre, 855 W. 12th Ave., Vancouver, B.C., V5Z IM9 Canada.
² Department of Radiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka 565-0825, Japan.
³ Department of Radiology, College of Medicine, Soonchunhyang University, Seoul 140-210, Korea.
⁴ Department of Radiology, Samsung Medical Center, College of Medicine, Sungkyunkwan University, 50 Irwon-dong, Kangnam-ku, Seoul, 135-710 Korea.

Received March 19, 1999; accepted after revision June 16, 1999.

 
Address correspondence to N. L. Müller.

Abstract

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OBJECTIVE. The aim of the study was to compare the radiographic and the high-resolution CT findings of Mycoplasma pneumoniae pneumonia.

MATERIALS AND METHODS. The chest radiographs and 1.5-mm collimation CT scans obtained in 28 patients with serologically proven M. pneumoniae pneumonia were retrospectively reviewed. The radiographs and CT scans were analyzed independently by two observers.

RESULTS. The most common finding on radiography was the presence of air-space opacification (n = 24), which was patchy and segmental (n = 9) or nonsegmental (n = 15) in distribution. On high-resolution CT, areas of ground-glass attenuation were seen in 24 patients (86%) and air-space consolidation in 22 (79%). In 13 patients (59%), the areas of consolidation had a lobular distribution evident on CT. Nodules were seen more commonly on high-resolution CT (25 of 28 patients, 89%) than on radiography (14 patients, 50%) (p << 0.01, chi-square test). In 24 (86%) of the 28 patients, the nodules had a predominantly centrilobular distribution on CT. Thickening of the bronchovascular bundles was identified more commonly on CT (23 of 28 patients, 82%) than on radiography (five patients, 18%) (p << 0.01, chi-square test).

CONCLUSION. The lobular distribution, centrilobular involvement, and interstitial abnormalities in M. pneumoniae pneumonia are often difficult to recognize on radiography but can usually be seen on high-resolution CT.

Introduction

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Mycoplasma pneumoniae is a common cause of community-acquired pneumonia [1, 2, 3]. Although only 3-10% of patients with M. pneumoniae infection develop pneumonia, up to 30% of all pneumonias in the general population may be caused by M. pneumoniae [1, 2, 3, 4]. M. pneumoniae infection is typically a disease of children and young adults; however, it is estimated to cause more than 15% of pneumonias in patients older than 40 years [4]. M. pneumoniae pneumonia usually has a good prognosis [1, 3, 5], but it may occasionally be complicated by adult respiratory distress syndrome, massive pleural effusion bacterial superinfection, pulmonary fibrosis, or bronchiolitis obliterans [1]. Histologically, M. pneumoniae infection is characterized by the presence of acute cellular bronchiolitis, which may progress to bronchopneumonia [6, 7, 8, 9].

The patterns of presentation of M. pneumoniae infection on chest radiography are nonspecific, consisting of patchy areas of airspace consolidation, reticular interstitial infiltrates, or both [1, 3]. Gruden et al. [10] have recently shown that infectious bronchiolitis is characterized on high-resolution CT by the presence of centrilobular nodules in a patchy distribution. However, the study by Gruden et al. fails to mention bronchiolitis caused by M. pneumoniae. To our knowledge, there is limited information in the literature about the CT findings in M. pneumoniae infection [2].

The aim of the current study was to review the chest radiographic and CT features of serologically proven M. pneumoniae pneumonia in 28 patients and to compare the two imaging techniques in the assessment of the presence and distribution of parenchymal abnormalities.

Materials and Methods

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We retrospectively reviewed chest radiographs and high-resolution CT scans obtained in 28 patients with M. pneumoniae pneumonia. Patients were identified through a chart review of patients who had undergone chest CT for suspected pulmonary infection. The diagnosis of M. pneumoniae infection was confirmed by serologic tests (complement fixation, indirect hemagglutination) with elevated single titers or a fourfold rise in titer [11]. The patients were 8-69 years old (median, 32 years); only eight patients (29%) were older than 40 years. Eighteen patients were male and 10 female.

Chest radiography was limited to a standard posteroanterior projection. The median time between chest radiography and CT was 1 day (range, 0-4 days). CT scans were obtained with commercially available CT scanners (CT-W 2000, Hitachi Medical, Tokyo, Japan; 9800 HiSpeed Advantage, General Electric Medical Systems, Milwaukee, WI). CT scans were obtained at 10-mm intervals throughout the chest using 1.5-mm collimation and were reconstructed with a high-spatial-frequency algorithm. The images were photographed at window settings appropriate for the assessment of the lung parenchyma (level, -700 H; width, 1000-1500 H) and mediastinum (level, 30-40 H; width, 400-500 H).

Chest radiographs and CT scans were randomized, and the two studies (chest radiograph and CT images for each patient) were assessed separately by two chest radiologists. After analysis of interobserver agreement, the images were reviewed together with a third chest radiologist, and a final decision was reached by consensus. The observers were unaware of any clinical data except age and sex of the patient. For each case, the observers completed a scoring sheet of pertinent findings. Chest radiographs and CT scans were analyzed with regard to the pattern and distribution of pulmonary abnormalities. The patterns of parenchymal abnormalities were subdivided into air-space consolidation, ground-glass attenuation, nodules, irregular lines, and bronchovascular thickening. On CT scans, air-space consolidation was considered present when the vascular margins were obscured. Ground-glass opacification was defined as a hazy increase in attenuation without obscuration of vascular markings. On the chest radiographs, these two patterns (i.e., air-space consolidation and ground-glass opacification) were grouped together as air-space opacification. The distribution of each pattern was categorized as being predominantly in the upper, middle, or lower lung zone. On high-resolution CT, the anatomic distribution of air-space consolidation and ground-glass attenuation was classified as lobular, segmental, nonsegmental, or random and was further subclassified as subpleural, peribronchovascular, or random. Nodules were assessed according to diameter (<<3 mm, 3-10 mm, >>10 mm), location (upper, middle, or lower lung zone), and distribution (centrilobular, peribronchovascular, or random). The comparisons between chest radiographs and high-resolution CT scans were made using the chi-square test [12]. The interobserver variability was assessed using kappa statistics [12].

Results

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The most common radiographic and high-resolution CT findings are listed in Table 1. Radiographic features included unilateral (n = 17) or bilateral (n = 7) areas of air-space opacification, nodules (n = 14), peribronchovascular thickening (n = 5), and linear opacities (n = 3). In three (11%) of the 28 patients, the chest radiographs were interpreted as showing normal findings except for the presence of mild peribronchial thickening. Air-space opacification present in 24 patients was segmental in nine patients and nonsegmental in 15 patients (Fig. 1A). Air-space opacification involved predominantly the lower lung zones in 16 (67%) of 24 patients, the middle lung zones in five (21%), and the upper lung zones in three (13%). The nodules seen in 14 patients measured less than 3 mm (n = 4) or between 3 and 10 mm (n = 10) in diameter and were most numerous in the lower (n = 8), upper (n = 2), and middle (n = 4) lung zones. Thickening of the bronchovascular bundles was evident in five patients, and linear opacities were seen in three (Fig. 2A). Small pleural effusions were noted in two patients and hilar lymphadenopathy in three.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 . —40-year-old woman with Mycoplasma pneumoniae pneumonia. A, Chest radiograph reveals patchy areas of nonsegmental air-space opacification in both lower lobes.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 . —30-year-old man with Mycoplasma pneumoniae pneumonia. A, Chest radiograph reveals coarse reticulation and thickening of bronchovascular bundles in right lower lobe.

On high-resolution CT, areas of ground-glass attenuation were identified in 24 (86%) of 28 patients. These areas had no zonal predominance and tended to be around areas of consolidation. In 11 (46%) of the 24 patients, the areas of ground-glass attenuation had a lobular distribution involving entire secondary lobules while sparing adjacent lobules (Figs. 3 and 4). In all 24 patients, the areas of ground-glass attenuation were seen as part of a mixed pattern including areas of air-space consolidation (n = 19), nodules (n = 22), and thickening of the bronchovascular bundles (n = 20).

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 . —17-year-old boy with Mycoplasma pneumoniae pneumonia. High-resolution CT scan (1.0-mm collimation) at level of right lower lobe reveals nodules smaller than 10 mm in diameter (arrows) in predominantly centrilobular distribution and areas of ground-glass attenuation. Note sharp demarcation between normal and abnormal secondary pulmonary lobules, consistent with lobular pneumonia.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 . —24-year-old man with Mycoplasma pneumoniae pneumonia. High-resolution CT scan (1.0-mm collimation) through right lung shows lobular areas of air-space consolidation (arrow) in medial segment of middle lobe. Note focal areas of ground-glass attenuation and poorly defined nodules in superior segment of right lower lobe.

Air-space consolidation was observed on CT in 22 patients (79%). The consolidation involved the lower lobes in 14 patients, the middle lobe or lingula in three, and the upper lobes in two; in the remaining three patients, more than one lobe was involved. A lobular distribution of consolidation was present in 13 (59%) of the 22 patients (Fig. 4). The consolidation was predominantly subpleural in five patients, predominantly peribronchovascular in four patients, and random in five patients; eight patients had both subpleural and peribronchovascular areas of consolidation. In all 22 patients with air-space consolidation, this pattern was seen in association with other findings including areas of ground-glass attenuation (n = 21), nodules (n = 21), and peribronchovascular thickening (n = 22) (Figs. 1B and 2B). Nodules were observed on CT in 25 patients (89%) and were the only finding in one patient. Nodules were bilateral in 10 patients and unilateral in 15 patients. Nodule diameter was less than 3 mm in five patients, 3-10 mm in 19 patients, and greater than 10 mm in one patient. The nodules had a centrilobular (n = 24) and peribronchovascular distribution (n = 14) and involved mainly the lower lung zones (Fig. 5).

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 . —40-year-old woman with Mycoplasma pneumoniae pneumonia. B, High-resolution CT scan (1.5-mm collimation) of right lung shows focal areas of air-space consolidation in nonsegmental distribution and multiple, partly confluent air-space nodules in centrilobular distribution.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 . —30-year-old man with Mycoplasma pneumoniae pneumonia. B, High-resolution CT scan (1.5-mm collimation) targeted to right lung shows nonsegmental subpleural air-space consolidation (curved arrow), centrilobular nodules (straight arrow), extensive areas of ground-glass attenuation, and interlobular septal thickening.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 . —55-year-old man with Mycoplasma pneumoniae pneumonia. A and B, High-resolution CT scans (1.0-mm collimation) at level of right upper (A) and lower (B) lobes show poorly defined nodular and branching areas of increased attenuation with predominantly centrilobular distribution (straight arrow, B) and bronchial wall thickening (curved arrow, A and B).

CT revealed thickening of the bronchovascular bundles in 23 patients (82%) and interlobular septal thickening in six patients (21%) (Fig. 5B). Pleural effusions were seen on CT in two patients and hilar or mediastinal lymphadenopathy in seven patients. No significant difference was seen in the prevalence of air-space opacification between chest radiography and high-resolution CT (p >> 0.10, chi-square test). Nodules were seen more commonly on high-resolution CT scans (25 [89%] of 28 patients) than on chest radiographs (14 [50%] of 28 patients) (p << 0.01, chi-square test). Bronchovascular thickening was also more frequently detected on high-resolution CT (23 [82%] of 28 patients) than on chest radiography (five [18%] of 28 patients) (p << 0.01, chi-square test). The interobserver agreement (kappa statistics) for the radiographic findings was 0.67 for the presence of air-space opacification, 0.50 for the presence of nodules, and 0.68 for the presence of peribronchovascular thickening. The interobserver agreement for the CT findings was 0.68 for the presence of consolidation, 0.83 for ground-glass attenuation, 0. 85 for presence of nodules, and 0.70 for thickening of bronchovascular bundles.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 . —55-year-old man with Mycoplasma pneumoniae pneumonia. A and B, High-resolution CT scans (1.0-mm collimation) at level of right upper (A) and lower (B) lobes show poorly defined nodular and branching areas of increased attenuation with predominantly centrilobular distribution (straight arrow, B) and bronchial wall thickening (curved arrow, A and B).

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
M. pneumoniae pneumonia can result in a wide spectrum of symptoms ranging from a classic presentation with fever, cough, and sputum production to more subtle and nonspecific manifestations such as fatigue, malaise, and myalgia [3, 13]. Histopathologically, M. pneumoniae pneumonia is characterized by acute cellular bronchiolitis with edematous and ulcerative lesions of the bronchial walls and by peribronchial and perivascular interstitial opacities containing lymphocytes, plasma cells, and macrophages [6, 7, 8, 9]. The alveoli surrounding involved bronchioles contain a mononuclear cell infiltration. Parenchymal involvement consists of bronchopneumonia with a lobular distribution. The inflammatory process typically respects interlobular septal boundaries, involving some secondary pulmonary lobules while sparing others [6, 7]. In severe cases, diffuse alveolar damage with fibrinous exudates and hyaline membrane formation may develop [7].

The most common radiographic findings consist of unilateral or bilateral areas of air-space consolidation or ground-glass opacities.

However, the findings are variable and can include reticular or nodular opacities. Associated features include bronchial wall thickening and, occasionally, small pleural effusions [7, 14].

In a study of 100 patients with M. pneumoniae pneumonia, two distinct patterns were recognized on chest radiography: 48% of patients showed segmental or lobar air-space consolidation, and 28% of patients showed a diffuse reticulonodular pattern with no evidence of air-space opacification [15]. In our study group, the most frequent chest radiographic finding was air-space opacification, seen in 86% of patients and most commonly involving the lower lobe. Nodular opacities were detected in 14 patients (50%).

In the current study, the findings of bronchiolitis and lobular consolidation seen in histologic specimens were seldom apparent on radiography but were commonly evident on CT. In our patients, the most distinct abnormality seen on CT consisted of poorly defined centrilobular nodules, consistent with bronchiolitis. The areas of patchy air-space consolidation or ground-glass attenuation frequently had a lobular distribution, a characteristic histologic feature of bronchopneumonia. Although the main abnormalities were in the air spaces, thickening of the axial interstitium and interlobular septa was commonly seen. Compared with chest radiography, CT more accurately showed the presence and extent of centrilobular nodules and the lobular distribution of consolidated areas and ground-glass opacities not visible on chest radiographs. Centrilobular nodules were detected in 50% of chest radiographs and 89% of high-resolution CT scans (p << 0.01). The high prevalence of centrilobular nodules in patients with M. pneumoniae pneumonia in the current study and the patchy distribution of the nodules are similar to the findings of Gruden et al. [10] in other infectious causes of bronchiolitis. Gruden et al. showed that the presence of centrilobular nodules in a patchy distribution is characteristic of infectious bronchiolitis, allowing distinction from noninfectious causes of bronchiolitis, which usually have a diffuse distribution throughout both lungs.

Clearly, chest radiography is the first imaging technique performed in the examination of patients with community-acquired pneumonia. In most of these patients, chest radiography provides adequate imaging information and high-resolution CT is not warranted. However, an increasing number of patients undergo CT, especially high-resolution CT, when there is a high clinical suspicion for pneumonia with normal or questionable radiographic findings. Syrjälä et al. [16] prospectively compared high-resolution CT with chest radiography in 47 patients with clinical symptoms and signs suggestive of community-acquired pneumonia. Evidence of pneumonia was identified on high-resolution CT in 26 patients compared with 18 on radiography (p << 0.01) [16]. CT examination is also requested in patients with known pulmonary infection when the patient fails to respond to appropriate therapy to assess the presence of complications or evidence of mixed infections. High-resolution CT is superior to radiography in showing the pattern and extent of abnormalities. In the study by Syrjälä et al., evidence of bilateral pneumonia was seen on high-resolution CT in 16 (34%) of 47 patients with clinically suspected community-acquired pneumonia compared with six (13%) on radiography. Many patients with M. pneumoniae pneumonia have nonspecific clinical findings and may be suspected clinically of having interstitial or airway lung disease. Under these circumstances, high-resolution CT may be ordered by the clinician. The main value of our study is to increase awareness of M. pneumoniae pneumonia when assessing the high-resolution CT findings in patients with nonspecific or questionable clinical and radiographic findings. The presence of centrilobular nodules in a patchy distribution should suggest the diagnosis of infectious bronchiolitis. The main infectious considerations would include endobronchial spread of tuberculosis, viral bronchiolitis, and M. pneumoniae pneumonia.

Our study has several limitations. It is retrospective and includes a small number of patients. Because M. pneumoniae pneumonia is rarely fatal, pathologic changes in M. pneumoniae infection have been described infrequently [3, 7]. In our series, correlation between CT and histopathologic features was not possible because none of the patients underwent biopsy.

In summary, the high-resolution CT findings of M. pneumoniae pneumonia consist mainly of centrilobular nodules, unilateral or bilateral consolidation often in a lobular distribution, and thickening of the peribronchovascular and interlobular septal interstitium. The lobular distribution, centrilobular involvement, and interstitial abnormalities in M. pneumoniae pneumonia are often difficult to recognize on radiography but can usually be seen on high-resolution CT.

References

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1. Mansel JK, Rosenow EC, Smith TF. Mycoplasma pneumoniae pneumonia. Chest 1989;95:639-646[Free Full Text]
2. Tanaka N, Matsumoto T, Kuramitsu T, et al. High resolution CT findings in community-acquired pneumonia.. J Comput Assist Tomogr 1996;20:600-608[Medline]
3. Fraser RS, Pare PJA, Fraser RG, Pare PD. Synopsis of diseases of the chest, 2nd ed. Philadelphia: Saunders, 1994:354-356
4. Talkington DF, Thacker WL, Keller DW, et al. Diagnosis of Mycoplasma pneumoniae infection in autopsy and open-lung biopsy tissues by nested PCR. J Clin Microbiol 1998;4:1151-1153
5. Moine P, Vercken JB, Chevret S, Chastang C, Gajdos P, and the French study group for community-acquired pneumonia in the intensive care unit. Severe community acquired pneumonia: etiology, epidemiology, and prognosis factors. Chest 1994; 105 :1487-1495[Abstract/Free Full Text]
6. Heitzman R. Lobar or bronchopneumonia. In: Heitzman R, ed. The lung: radiologic-pathologic correlations, 2nd ed. St. Louis: Mosby, 1984:194-234
7. Miller RR. Mycoplasma, Chlamydia, and Coxiella infections of the respiratory tract. In: Thurlbeck WM, ed. Pathology of the lung. New York: Thieme, 1988:223-227
8. Müller NL, Miller RR. Diseases of the bronchioles: CT and histopathologic findings. Radiology 1995;176:243-248
9. Worthy SA, Müller NL. Small airway diseases. Radiol Clin North Am 1998;36:163-173[Medline]
10. Gruden JF, Webb RW, Naidich DP, McGuinness G. Multinodular disease: anatomic localization at high-resolution CT—multireader evaluation of a simple algorithm. Radiology 1999;210:711-720[Abstract/Free Full Text]
11. Ali NJ, Sillis M, Andrews BE, Jenkins F, Harrison BDW. The clinical spectrum and diagnosis of Mycoplasma pneumoniae infection. Q J Med 1986,227:241-251
12. Dawson-Saunders B, Trapp RG. Basic and clinical biostatistics. San Mateo, CA: Appleton & Lange, 1990:58-59, 149-161
13. Guckel C, Benz-Bohm G, Wideman B. Mycoplasma pneumonias in childhood: roentgen features, differential diagnosis and review of literature. Pediatr Radiol 1989;19:499-503[Medline]
14. Cameron DC, Borthwick RN, Philip T. The radiographic patterns of acute Mycoplasma pneumonitis. Clin Radiol 1977;28:173-180
15. Putman CE, Curtis A, Simeone JF, Jensen P. Mycoplasma pneumonia: clinical and roentgenographic patterns. AJR 1975;124:417-422[Abstract]
16. Syrjälä H, Broas M, Ojala A, Lahde S. High-resolution computed tomography for the diagnosis of community-acquired pneumonia. Clin Infect Dis 1998;27:358-363[Medline]

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