5 Algoritimo cavidades pulmonares

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[ Special Features ]
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Cavitary Lung Diseases
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A Clinical-Radiologic Algorithmic Approach
Khalid Gafoor, DO; Shalin Patel, MD; Francis Girvin, MD; Nishant Gupta, MD, FCCP; David Naidich, MD, FCCP;
Stephen Machnicki, MD; Kevin K. Brown, MD, FCCP; Atul Mehta, MD, FCCP; Bryan Husta, MD, FCCP;
Jay Ryu, MD, FCCP; George Sarosi, MD; Tomás Franquet, MD; Johny Verschakelen, MD; Takeshi Johkoh, MD, PhD;
William Travis, MD; and Suhail Raoof, MD, Master FCCP
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ABBREVIATIONS: CNA = ch
granulomatosis with polyangii
invasive pulmonary aspergill
complex; NTM = nontubercu
arthritis
AFFILIATIONS: From the Pul
and Patel), Lenox Hill Hosp
Radiology (Drs Girvin and Na
Pulmonary, Critical Care and S
Cincinnati; Radiology (Dr Ma
Husta and Raoof), Lenox Hill H
Jewish Health; Pulmonary (Dr
CCM (Dr Ryu), Mayo Cli
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Cavities occasionally are encountered on thoracic images. Their differential diagnosis is large
and includes, among others, various infections, autoimmune conditions, and primary and
metastatic malignancies. We offer an algorithmic approach to their evaluation by initially
excluding mimics of cavities and then broadly classifying them according to the duration of
clinical symptoms and radiologic abnormalities. An acute or subacute process (< 12 weeks Q)
suggests common bacterial and uncommon nocardial and fungal causes of pulmonary
abscesses, necrotizing pneumonias, and septic emboli. A chronic process (> 12 weeks)
suggests mycobacterial, fungal, viral, or parasitic infections; malignancy (primary lung cancer
or metastases); or autoimmune disorders (rheumatoid arthritis and granulomatosis with
polyangiitis). Although a number of radiographic Qfeatures can suggest a diagnosis, their lack of
specificity requires that imaging findings be combined with the clinical context to make a
confident diagnosis. CHEST 2018; -(-):---
KEY WORDS: cavitary; cavitating infections; cavitation; focal lucencies; necrotic lesions Q
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To date, there are few specific guidelines
published on the optimal approach to
cavitary lung disease.1,2 The intention of
this review is to highlight the specific
clinical, laboratory, and radiographic
features that can help guide clinicians in
their approach. For purposes of this report,
radiographic findings refer to abnormal
chest imaging features seen on CT scans of
the chest.
ronic necrotizing aspergillosis; GPA =
tis; ILD = interstitial lung disease; IPA =
osis; MAC = Mycobacterium avium
lous mycobacteria; RA = rheumatoid
monary Medicine Division (Drs Gafoor
ital-Northwell Health; Department of
idich), NYU—Langone Medical Center;
leep Medicine (Dr Gupta), University of
chnicki) and Pulmonary Division (Drs
ospital; Medicine (Dr Brown), National
Mehta), Cleveland Clinic; Pulmonary/
nic; Infectious Diseases (Dr Sarosi),
Minneapolis V
Franquet), Ho
schakelen), U
Kinki Central
Teachers; and
Kettering Can
CORRESPOND
Lenox Hill H
suhailraoof@g
Copyright � 2
Elsevier Inc. A
DOI: https://d
.0 DTD � CHEST1599_proof � 13 April 2018 � 10:
A cavity, as defined by the Fleischner Society,
is a gas-filled space, seen as a lucency or
low-attenuation area, within a nodule, mass,
or area of parenchymal consolidation.3 It has
a clearly defined wall > 4 mm thick.2
Although any strict definition would be
arbitrary, we suggest that acute and subacute
cavities are those < 12 weeks old (according
to prior imaging or duration of symptoms),
and chronic cavities are > 12 weeks old. We
A Health Care System; Department of Radiology (Dr
spital de la Santa Q5Creu i Sant Pau; Radiology (Dr Ver-
niversity Hospital Gasthuisberg; Radiology (Dr Johkoh),
Hospital of Mutual Aid Association of Public School
Department of Pathology (Dr Travis), Memorial Sloan
cer Center.
ENCE TO: Suhail Raoof, MD, Pulmonary Division,
ospital, 130 E 77th St, New York, NY 10075 Q6; e-mail:
mail.com
018 American College of Chest Physicians. Published by
ll rights reserved.
oi.org/10.1016/j.chest.2018.02.026
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mailto:suhailraoof@gmail.com
https://doi.org/10.1016/j.chest.2018.02.026
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derived the definition of “chronic” from the US National
Center for Health Statistics, which defines a chronic
condition as one lasting 12 weeks (3 months) or longer.4
Before we delve deeper into a discussion about cavitary
lung disease, it is important to discuss conditions that
mimic cavities. These include cysts, emphysema,
infected bullae, and cystic bronchiectasis.
It is also helpful to recognize the chest imaging findings
that can guide clinicians to a particular diagnosis. For
example, multiple peripheral nodules in varying stages
of cavitation (Fig 1) indicae septic emboli, pulmonary
Langerhans cell histiocytosis, or possible infarction.
Bronchiectasis and accompanying peripheral small
airways disease (Fig 2) typically indicate widespread
chronic infection. Halo (Fig 3) and reversed halo (Fig 4)
signs often are seen in association with various
rheumatologic diseases, infections (including fungal),
septic emboli, pulmonary infarcts, and malignancies,
especially metastatic disease with hemorrhage such as
choriocarcinoma. An irregular internal wall (Fig 5) is
seen more frequently in malignant cavitary lesions.
Linear outer border, associated bronchial wall
thickening, satellite nodules, consolidation, and ground-
glass opacities are associated more commonly with
benign cavitary lesions.
Algorithmic Approach
In our algorithmic approach (Fig 6), we begin with
ensuring that the lesions visible on CT scans are cavitary
lesions. It is important to distinguish these lesions from
mimics of cavitary lesions. We emphasize accompanying
radiologic features that may point toward specific
causes. In addition, we discuss how acuity or chronicity
of cavitation, clinical features, and other laboratory
indexes influence the likelihood of diagnosis.
Comparison with prior imaging, when available, is
helpful in gauging the tempo of the disease process—a
Figure 1 – Axial CT scan obtained in a 55-year-old man with a skin
abscess leading to methicillin-resistant Staphylococcus aureus bacter-
emia and septic emboli. There are multiple nodules in varying stages of
cavitation.
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rapidly evolving cavity (< 12 weeks) strongly suggests
an acute infectious cause. In contrast, cavities with a
more chronic or indolent evolution (> 12 weeks)
suggest chronic infections, autoimmune conditions, or
malignancy. However, there may be significant overlap
in temporal evolution of cavitary disease processes,
depending in part on the patient’s immune status and
comorbidities.
Step 1: Are We Dealing With True Cavities?
True cavities must be differentiated from their mimics,
such as cystic disease, emphysema, infected bullae, and
cystic bronchiectasis. The definitions and radiologic
appearances of these mimics that distinguish them from
cavities are summarized in Table 1.5-8
Step 2: Assess Disease Duration
Use the patient’s history and previous chest images to
estimate disease duration. If the estimated disease
duration suggests an acute or subacute process
(< 12 weeks), see step 3. If it is more than 12 weeks,
see step 4.
Step 3: Acute and SubacuteCavities (< 12 Weeks
in Duration)
Although the differential diagnosis of an acute or
subacute cavity is wide, the first step is to rule out recent
infection. Clinical features suggesting infection include
fever, chills, and cough.9 Laboratory values that suggest
an acute bacterial infection include sputum cultures
demonstrating respiratory pathogens, elevated white
blood cell count with shift to the left, and elevated
procalcitonin C levels. For fungal infections, blood
cultures, b-D-glucan level, galactomannan level, as well
as measurements of specific fungal antigens in the blood
and urine, may be important. Cavitary Mycobacterium
tuberculosis can manifest acutely; however, it is more
likely to have a chronic manifestation and is discussed
later. Common infectious causes, including bacterial
lung abscesses, necrotizing pneumonias, septic emboli,
and acute fungal infections, are described here and
summarized in Table 2.
Bacterial Pathogens: Lung abscesses are pus-
containing necrotic lesions of the lung parenchyma
that show an air-fluid level at chest imaging. Microbial
cultures performed from lung abscesses usually
demonstrate multiple pathogens.10-12 These include
microaerophilic streptococci and viridans streptococci,
which were considered the most common.13 However,
studies from Japan and Taiwan have implicated both
Streptococcus species and Klebsiella pneumoniae as the
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Figure 2 – A-B, Axial CT scans (A, B) obtained in a 52-year-old man with culture-positive Mycobacterial tuberculosis. Thick-walled cavity and
multiple tree-in-bud opacities appear posteriorly in the apical segment of the right upper lobe.
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most frequent causes of cavitary disease, suggesting
that the bacteriologic aspects of cavity formation may
be changing.13,14 Less frequently isolated organisms
include Staphylococcus aureus, Pseudomonas
aeruginosa, Haemophilus influenzae (type B),
Acinetobacter species, Escherichia coli, and Legionella
species. Contributing clinical factors are alcoholism,
diabetes mellitus, generalized convulsive disorders,
drug abuse, older age, and dental infections.15 Patients
often have high fevers, night sweats, cough with foul-
smelling sputum, hemoptysis, fatigue, and weight loss.
These symptoms can go on for weeks—longer than
what is typical for community-acquired pneumonia.
Laboratory test abnormalities include leukocytosis with
a left shift and elevated values of C-reactive protein
Figure 3 – Axial high-resolution CT scan demonstrates a solid central
nodule surrounded by ground-glass opacity—the halo sign.
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level, erythrocyte sedimentation rate, and procalcitonin
C level.10 Radiographically, a lung abscess appears as a
cavity with thick walls, irregular luminal margins and
outer borders and typically demonstrates an air-fluid
level (Fig 7). Lung abscesses are usually unilateral and
solitary and predominantly occur in the posterior
segments of the upper lobes and superior segments of
the lower lobes. This distribution is particularly
suggestive of prior aspiration—a diagnosis suggested
by the finding of centrilobular, tree-in-bud opacities in
a similar anatomic distribution on prior chest imaging
studies.16,17 Pleural effusion and empyema have been
associated with lung abscesses 25% and 8% of the time,
respectively.18
Necrotizing pneumonia is a rare but severe complication
of a bacterial infection.19,20 Acute necrotizing
pneumonia often is caused by S aureus, Streptococcus
pneumoniae, K pneumoniae, H influenzae, and P
aeruginosa.21 Of special interest is community-acquired
methicillin-resistant S aureus containing the gene for
Panton-Valentine leukocidin, a toxin known to cause
necrotizing pneumonia with rapid development of
respiratory failure and shock.19 Clinical factors
contributing to the development of acute necrotizing
pneumonia are similar to those in lung abscesses and
include diabetes mellitus, alcohol abuse, and
corticosteroid therapy. Patients with acute necrotizing
pneumonia typically appear severely ill with cough,
fever, hypoxia, tachycardia, and tachypnea and rapidly
progress to respiratory failure and septic shock.
Laboratory test abnormalities are similar to those found
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Figure 4 – A-B, Axial CT scan (A) obtained in a 47-year-old woman with acute myelogenous leukemia and pulmonary mucormycosis. There is central
ground-glass attenuation with a rim of more dense consolidation— the reversed halo sign. There is small adjacent ground-glass opacity. Axial CT scan
(B) obtained in a 57-year-old man with aortic valve endocarditis and septic emboli. The left lower lobe has subpleural air-space opacity, comprising
central ground-glass attenuation and a rim of more dense peripheral consolidation, consistent with the reversed halo sign. Also, there are several
nodules at the right base, including a cavitary nodule medially.
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in lung abscesses, as previously mentioned.15,16
Characteristic radiographic findings include areas of
consolidation containing multiple foci of poorly defined
low attenuation areas suggestive of necrosis. These
changes are identified best on chest CT scans following
IV administration of contrast material. These areas
subsequently may coalesce to form larger cavities and, if
this process continues, can lead to frank lobar gangrene
(Fig 8).
Features on the CT scan that point toward lung
gangrene include obscuration of the pulmonary arterial
supply to the involved segment or lobe and paucity of
contrast material uptake in the lung parenchyma with
central necrosis affecting > 50% of the involved lobe
(Fig 9).22,23 Necrotizing pneumonia tends to occur in
regions of the lung that are less gravity dependent
Figure 5 – A-B, Coronal CT scan (A) obtained in a 66-year-old man demonst
superior segment of the left lower lobe. Pathologic test results helped confirm p
in a 66-year-old man demonstrating a thick-walled cavitary mass with an i
Pathologic test results helped confirm primary squamous cell carcinoma of t
4 Special Features
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compared with abscesses.19,24 Surgical intervention has
been recommended early on if lung necrosis and
gangrene have set in because antibiotic penetration to
the affected areas is compromised by diminished or
absent blood supply.25,26 Pleural effusions are
associated with necrotizing pneumonia approximately
23% of the time,24 some of which can be empyema.
The incidence of this complication is difficult to assess
because conclusions are drawn from small studies and
case reports. One study reports empyema in 6 of
100,000.27
Septic pulmonary emboli result from hematogenous
seeding from an infected extrapulmonary site.28 Risk
factors include IV drug use and infected invasive devices
such as central venous catheters and pacemakers and
other such as prosthetic valves. Septic thrombophlebitis,
rating a thick-walled cavitary mass with an irregular internal wall in the
rimary squamous cell carcinoma of the lung. Axial CT scan (B) obtained
rregular internal wall in the superior segment of the left lower lobe.
he lung.
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Mimics
Cysts
Emphysema
Infected Bullae
Cystic Bullae
Acute/subacute
(<12 weeks)
Step 3
Step 5 Step 6
Step 4
Step 2
Step 1
Step 7
Acute infections
Clinical History & Investigations:
Fever, chills, productive cough,
aspiration risk, elevated WBC,
elevated Pro-calcitonin
(bacterial infections)
Lung abscess
Necrotizing pneumonia
Septic emboli
Fungol infection
Nocardia
See Table 2 See Table 3 See Table 4 See Table 5
TB
NTB
Fungal
Parasitic
Viral
Primary lung
cancer
Metastatic to
lung
RA
GPA
CT features CT features CT features CT features
Clinical History &
Investigations:
Fevers, weight loss, chronic
cough, hemoptysis, fatigue
Clinical History & Investigations:
Older, Weight loss, chronic
cough, hemoptysis, fatigue,
smoking history,
history of malignancy
Clinical History & Investigations:
History of connective tissue
disease, arthralgia, myalgias,
rash, fever, positive serology.
Chronic Infections Malignancy Autoimmunity
Chronic
(>12 weeks)
Review old imaging studies (if available) +
Obtain history to determine duration of disease
Confirm cavities
(Exclude mimics)
Focal hyperluciencies-Suspect pulmonary cavitary disease
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Figure 6 – Algorithmic approach to cavitary lung disease. GPA ¼ granulomatosis Q39with polyangiitis.
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pelvic thrombophlebitis, and Lemierre syndrome also
may be implicated.1,29 Fever, dyspnea, chest pain, cough,
fatigue, and hemoptysis are frequently present.
Progression to respiratory failure, septic shock,
empyema, or renal failure can occur. Positive blood
cultures are common, and the most commonly isolated
organisms are staphylococcal species, Fusobacterium
necrophorum, K pneumoniae, and Streptococcus
viridans.29,30 Radiographically, septic emboli appear as
well-defined, peripheral or subpleural nodules of various
size (0.5-3.5 cm) with evidence of cavitation in up to
85% of patients. A characteristic feature is the finding of
nodules simultaneously appearing in various stages of
cavitation because of repeated seeding of the lungs, most
often from endocarditis. As further evidence of a
hematologic origin, nodules may be associated with
feeding vessels, variously reported in 67% to 100% of
cases (Fig 10).24,29,31-33
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Pulmonary nocardiosis most commonly is caused by
Nocardia asteroides, which is found primarily in soil; the
respiratory tract, skin, and GI tract are the primary
portals of infection. Patients with defects in cell-
mediated immunity are predisposed to infection,
including patients who have undergone solid organ or
stem cell transplant who are receiving
immunosuppressive therapy and those with AIDS,
lymphoma, and leukemia. Low-grade fevers, weight loss,
cough, fatigue, and chest pain are often present, and
acute respiratory failure can occur.10 The CNS is the
most common extrapulmonary site of infection with
Nocardia. Patients may have one or more brain
abscesses and can have symptoms of headache, nausea,
vomiting, seizures, or altered mental status.31
Radiographically, pulmonary nodules and consolidation
are common, and cavitation can occur in both (Fig 11).
Pulmonary nodules range in size from 0.6 to 2.9 cm.
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TABLE 1 ] Cavity Mimics Q20
Cavity Mimic Definition or Radiographic Appearance CT Scan
Cyst Round parenchymal lucency with a
well-defined thin wall (< 2 mm
thick)5
Emphysema Focal areas or regions of low
attenuation, usually without
visible walls6
Infected bullae Radiographic evidence of previous
bullous disease and the
development of an air-fluid level7
Cystic bronchiectasis Lack of bronchial tapering and an
increased bronchoarterial ratio8
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TABLE 2 ] Acute and Subacute Cavities
Cavity Patient Background Radiographic Findings Laboratory Findings
Lung abscess Alcoholism, diabetes mellitus,
convulsive disorders, drug
abuse, elderly, and dental
infections
High fevers, night sweats,
cough with foul-smelling
sputum, fatigue, and weight
loss
Typically unilateral and
solitary cavities with thick,
irregular walls, often with
an air-fluid level
Predominantly in the
posterior segments of the
upper lobes and superior
segments of the lower
lobes
Positive sputum cultures
Leukocytosis with left shift,
elevated procalcitonin C
level
Necrotizing
pneumonia
Diabetes mellitus, alcohol
abuse, and corticosteroid
therapy
Usually severely ill, may have
respiratory failure and shock
Usually unilateral and
solitary pulmonary
consolidation with multiple
foci of poorly defined low-
density areas suggestive
of necrosis
Tends to be more common in
regions of the lung that are
not gravity dependent
Positive sputum cultures
Leukocytosis, elevated
procalcitonin C level,
elevated ESR and CRP
level
Septic emboli Central venous catheters,
pacemakers, right-sided
prosthetic valves, IV drug
abuse, and Lemierre
syndrome
Fevers, dyspnea, chest pain,
cough may progress to
respiratory failure and septic
shock
Multiple, bilateral,
peripherally located
nodules that cavitate;
usually seen in different
stages of cavitation
May see a feeding vessel sign
Nodules may be 0.5-3.5 cm.
Positive blood cultures
Leukocytosis, elevated ESR
and CRP level
Nocardia Patients who have undergone
solid organ or stem cell
transplant who are receiving
immunosuppressive therapy
and patients with AIDS,
lymphoma, and leukemia
Low-grade fevers, weight loss,
and cough
Respiratory failure may occur.
Pulmonary nodules and
consolidation, most
commonly bilateral
Cavitation can occur in
both nodules and
consolidation. No zonal
predominance
75% of cases may have
crazy-paving appearance
around nodules, cavities,
masses, or consolidations
Nodules may be 0.6-2.9 cm.
Positive PCR results with
respiratory sample
Microscopy of respiratory
sample (gram positive
and modified acid fast)
Cryptococcus Exposure to aged pigeon
droppings More common in
patients who are
immunocompromised
Fever, cough, dyspnea,
headache May be
asymptomatic
Multiple bilateral, peripheral
nodules and masses that
cavitate
Nodules may be 0.7-2.8 cm.
Positive sputum culture
Positive serum latex
agglutination results
Positive for b-D-glucan
Coccidioidomycosis Severe disease is common in
hosts who are
immunocompromised and
travel to endemic regions
(Southwest United States,
Mexico, Central and South
America).
Profound fatigue, erythema
nodosum or erythema
multiforme, arthralgias,
cough, fever, subacute time
course
Focal or multifocal
consolidation is the most
common finding. Cavities
are seen in 2%-8% of
cases.
Phantom infiltrates may be
seen.
Nodules may be 0.5-3.0 cm.
Peripheral eosinophilia
May have positive BAL,
sputum, or lung biopsy
cultures
Positive complement
fixation, immunodiffusion,
and urine antigen
(Continued)
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TABLE 2 ] (Continued)
Cavity Patient Background Radiographic Findings Laboratory Findings
Invasive pulmonary
aspergillosis
Prolonged neutropenia, T-cell
deficiency, organ transplant
Fevers, cough, dyspnea,
hemoptysis unresponsive to
antibiotics
Solitary or multiple nodules
with a halo sign, and
1-2 weeks after the halo
sign appears the nodule
can cavitate leading to an
air crescent sign
Also may see pleural-based
wedge-shaped areas of
consolidation
Usually > 1 cm
Positive for serum
galactomannan and b-D-
glucan
Positive for BAL
galactomannan
Mucormycosis Poorly controlled diabetes and
immunocompromise
Patients are often severely ill,
with fevers, cough dyspnea,
and hemoptysis.
Radiographically similar to
IPA
Also may see reversed halo
sign more commonly than
in IPA
Organisms in tissue at
histopathologic
examination
Negative for b-D-glucan
CRP ¼ C-reactive protein; ESR ¼ erythrocyte sedimentation rate; IPA ¼ invasive pulmonary aspergillosis; PCR ¼ polymerase chain reaction.
Figure 7 – Axial CT scan obtained in 42-year-old man demonstrating
an irregular thick-walled cavity with dependent air-fluid level and
peripheral ground-glass halo involving the apical segment of the right
upper lobe and superior segment of the right lower lobe. Biopsy results
helped confirm abscess, but a specific pathogen was not isolated.
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Seventy-five percent of cases may have a crazy-paving
appearance around nodules, cavities, masses, or
consolidation.32 Crazy-paving is defined as an area of
ground-glass attenuation, frequently well defined, within
which a pattern of interlobular septal thickening can be
identified, restricted to the area of ground-glass
attenuation.33 Pleural effusion has been reported in
10% to 36% of cases. There also may be associated
bronchiectasis (40%).34-37 The diagnosis can be made
from microscopic examination of bronchial washings
and BAL with modified acid-fast stain and Gram stain
or positive polymerase chain reaction of the respiratory
sample.38,39
Fungal Pathogens: Cryptococcus neoformans is the most
common Cryptococcus species encountered in the
United States and other temperate climates in the world.
It is considered one of the principal pathogens in
humans and is found in soil and aged pigeon
droppings.40 Pulmonary involvement occurs after
inhalation of spores and more commonly affects
individuals who are immunocompromised.41 Patients
typically present with fever, cough, shortness of breath,
chest pain, and headache; however, some patients may
be asymptomatic.42,43 Radiographically, the common
manifestation is multiple bilateral, peripheral nodules
and masses, although a random distribution also has
been described. Pulmonary nodules range in size from
0.7 to 2.8 cm.44 Cavitation, when present, occurs within
nodules or masses and less commonly in foci of
air-space consolidation, especially in hosts who are
immunocompromised.42,45 Sputum culture, b-D-glucan
and serum latex agglutination test results may be
positive.46
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Coccidioidomycosis is caused by the fungus
Coccidioides. This organism is endemic in the soil of the
southwestern United States, parts of Mexico, and
Central and South America. Infection results from the
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Figure 8 – A-D, Necrotizing pneumonia. Axial CT scans (A, B) of the right lung with lung and soft-tissue windows. There is a large area of
consolidation with surrounding ground-glass opacity and septal thickening in the right lower lobe. Areas of lucency within the consolidation are
consistent with cavitation. No pathogen was identified. Acute necrotizing pneumonia (STAIN, �0 magnification Q25). Low-power image (C) shows
cavitation at the bottom of the image surrounded by marked acute inflammation. Acute necrotizing pneumonia (STAIN, �0 magnification). A
neutrophilic abscess at the bottom center of the image (D) is surrounded by marked acute and chronic inflammation with a few giant cells.
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inhalation of aerosolized spores and occurs in patients
living in endemic regions or traveling to these areas.47
Risk factors include AIDS, hematologic malignancies,
pregnancy, diabetes, cardiopulmonary disease, smoking,
and male sex. In primary coccidioidal infection (acute),
the majority of patients (60%-80%) are either
asymptomatic or have mild influenza-like symptoms.
Figure 9 – A-B, Necrotizing pneumonia. Axial contrast-material-enhanced C
who presented with shortness of breath, lethargy, and septic shock. Stenotroph
There is dense consolidation in both lower lobes, with cavitation and nonen
contrast-material-enhanced CT scan (B) obtained in the mediastinal window
from granulomatosis with polyangiitis. A lung mass with a central area of n
(yellow arrow), suggesting necrosis. A nodule with a similar appearance is p
surrounded by a rim of enhancement.
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Others will develop symptoms similar to an acute
bacterial pneumonia such as cough, fever, and chest
pain. In highly endemic areas, up to 29% of patients with
community-acquired pneumonia have
coccidioidomycosis.48 Some distinguishing features are
profound fatigue, erythema nodosum or erythema
multiforme, arthralgias, and subacute time course.10,49-51
T scan (A) obtained in the mediastinal window in a 74-year-old woman
omonas and methicillin-sensitive Staphylococcus aureus were in sputum.
hancing lung (arrow) in the right lower lobe. Necrotic lung mass. Axial
in a 62-year-old woman with lung, skin, liver, and joint involvement
onenhancing lung (red arrow) is surrounded by a rim of enhancement
osterior to the lung mass with a central area of nonenhancing lung
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Figure 10 – A-B, Septic emboli. Coronal (A) and axial (B) scans obtained with lung windows demonstrate multiple nodules in different stages of
cavitation in both lungs. Ground-glass opacity surrounds the cavity in the left apex. A feeding vessel sign (arrow) is visible adjacent to that cavity as
well. Note the right-sided central line.
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The most common radiologic manifestation of the acute
form is focal or multifocal consolidation. Pulmonary
nodules are another common feature and are similar in
size to the nodules seen with Cryptococcus. Cavities are
seen in 2% to 8% of acute primary infections. These tend
to resolve spontaneously but can persist to become
chronic cavities. Another feature is phantom infiltrates
in which parenchymal consolidation appears at one site,
resolves, and then reappears in a new location.52 A
peripherally located cavity can rupture into the pleural
space causing a pneumothorax (Fig 12).52 Diagnostic
tests include complement fixation, immunodiffusion,
and urine examination for fungal antigen.53,54
Figure 11 – Pulmonary Nocardia. Axial CT scan obtained with lung
windows in a 62-year-old man receiving long-term steroid therapy for
polymyalgia rheumatica hospitalized for recurrent cough, fevers, and
night sweats demonstrates an area of consolidation with central cavi-
tation in the right upper lobe. There is a small adjacent ground-glass
opacity.
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Aspergillus is a commonly found environmental mold
that can cause a variety of pulmonary diseases, including
aspergilloma, chronic necrotizing aspergillosis (CNA),
and invasive pulmonary aspergillosis (IPA). In the host
who is immunocompromised, inhaled Aspergillus can
invade the vasculature, with subsequent infarction and
tissue necrosis. IPA is seen primarily in patients with
prolonged neutropenia, solid organ transplants, or T-cell
deficiencies. Other risk factors include COPD, long-term
steroid therapy, diabetes, and liver cirrhosis.55
Symptoms of pneumonia, including productive cough,
dyspnea, chest pain, hemoptysis, and fevers
unresponsive to antibiotics, are typical. Laboratory test
result abnormalities may include a finding positive for
galactomannan and b-D-glucan.56 A number of imaging
findings have been reported to occur due to infection
with Aspergillus. Of these, acute cavitation is most likely
to be identified in its invasive form. IPA
characteristically manifests with multiple pulmonary
nodules, often > 1 cm,57 associated with a halo sign
(Fig 13A), which is defined as ground-glass attenuation
surrounding a solid central core; the ground-glass
component represents pulmonary hemorrhage due to
the angioinvasive nature of Aspergillus. One to 2 weeks
after the halo sign appears, especially following
successful treatment, nodules cavitate in up to 63% of
patients, leading to an air crescent sign, as a result of
tissue necrosis (Fig 13B).56,58,59 Another radiologic
appearance of IPA includes pleura-based wedge-shaped
areas of consolidation whose findings correspond to
hemorrhagic infarcts.57
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Figure 12 – A-B, Chest radiograph (A) and axial CT scan (B) obtained in 22-year-old man initially thought to have a spontaneous pneumothorax.
Radiographs and CT scans demonstrated a hydropneumothorax in the right lung and a solitary thick-walled cavity at the right apex. Wedge resection
demonstrated granulomatous inflammation, and Coccidioides immitis and C posadasii were identified with sputum culture and polymerase chain
reaction.
Figure 13 – A-B, Axial CT scan (A) demonstrates multiple solid nodules surrounded by ground-glass opacities or ill-defined fuzzy margins—the halo
sign. Coronal high-resolution CT scan (B) demonstrates a crescentic lucency surrounding the nodule—the air crescent sign. This image is from a
different patient from the patient in Figure 13A.
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Mucormycosis is an infection caused by molds
belonging to the order Mucorales. Rhizopus and Mucor
are the two genera most commonly noted to cause
infection. These molds are ubiquitous and are found in
soil and decaying plant material. They gain access to the
host via inhalation, skin penetration, and less frequently
ingestion. The most frequently affected are those with
poorly controlled diabetes and those who are
immunocompromised.60 Patients are often severely ill
and present with fevers, cough, dyspnea, pleuritic chest
pain, and hemoptysis. At laboratory analysis, a positive
b-D-glucan result is not found because Mucor and
Rhizopus do not produce this polysaccharide. A
diagnosis is usually made by means of histopathologic
testing.10,61 Radiographically, the manifestation overlaps
with that of IPA. More commonly than in IPA, a
reversed halo sign may be seen, which is defined as
curvilinear solid density surrounding a core of ground-
glass attenuation (Fig 4).62 As with IPA masses, nodules,
a halo sign, consolidation, and cavitation are all
seen.61,63,64 Cavity formation can occur after the
reversed halo sign or halo sign is noted.64,65 Although
neither the halo nor the reversed halo sign is
pathognomonic of IPA or mucormycosis, their presence
is sufficiently suggestive, especially in the setting of a
host who is immunocompromised, to warrant initial
empiric therapy.
Step 4: Chronic Cavities (> 12 Weeks in Duration)
The differential diagnosis includes chronic infections,
malignancy, and autoimmune disorders. On the
basis of the clinical context, we can direct our
differential diagnosis into one of these three disease
categories.
Chronic infections and malignancy are suggested by
fevers, weight loss, chronic cough, hemoptysis, and
fatigue. However, malignancy is more likely in a patient
with a smoking history, older age, and a personal or
family history of cancer. If the clinical context suggests a
chronic infection, see step 5. If the clinical context
suggests malignancy, see step 6. Chronic infections are
summarized in Table 3; malignancy is summarized
in Table 4.
Autoimmune disorders are suggested by a history of
connective tissue disease, arthralgias, myalgias, and
positive serologic test results. If the clinical context
suggests autoimmune disorders, see step 7. Autoimmune
disorders are summarized in Table 5.
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Step 5: Chronic Infections
Mycobacterial Disease: TB is caused by M tuberculosis.
In more than 90% cases, it is a reactivation of a latent
infection. The risk of conversion to active disease is
estimated to be up to 10% through a patient’s entire
lifetime and is higher in patients who are
immunocompromised.66,67 Patients with pulmonary TB
can present with chronic cough, sputum production,
weight loss, fevers, night sweats, loss of appetite, and
hemoptysis. These patients may have HIV coinfection orcome from an endemic region.68 Patients with
tuberculosis may have a positive interferon gamma
release assay, tuberculin skin test, or sputum microscopy
or culture.65,68 Radiographically, fibrocavitary disease
occurs in approximately 50% of patients with
reactivation TB and is seen more often in the apical and
posterior segments of the upper lobes or the superior
segments of the lower lobes. Fibrocavitary disease is
defined radiographically as pulmonary infiltrates
characterized by nodular densities, linear fibrous scars,
volume loss due to scarring, and cavitation.68 Multiple
cavities usually are present and appear thick walled with
irregular inner margins, which can become thin and
smooth with treatment (Fig 2).69-71
Nontuberculous mycobacteria (NTM) are ubiquitous in
the environment, but concentrations are highest in water
and soil. The most common organism associated with
pulmonary disease is Mycobacterium avium complex
(MAC), a term that encompasses many subspecies. To
date, two distinct populations of patients have been
identified as frequently infected. The first group is
defined by underlying risk factors that include profound
immunosuppression such as HIV; transplant; or
structural lung disease with architectural distortion such
as COPD, silicosis, prior TB infection, or cystic
fibrosis.72-74 Patients in this setting can present with
chronic productive cough, hemoptysis, malaise, fatigue,
and weight loss. Patients with NTM may have positive
sputum microscopy or culture results. Radiographically,
MAC appears similar to reactivation TB, with upper
lobe fibrocavitary disease (Figs 14A-D); however,
cavities due to MAC may be smaller or thin walled, and
disease may progress more slowly. Common associated
imaging findings include tree-in-bud opacities and
bronchiectasis.75-77
A second group of individuals at risk for NTM infection
are elderly women who present with chronic
nonproductive cough and weight loss. This group tends
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TABLE 3 ] Chronic Infection
Chronic Infection Patient Background Radiographic Findings Laboratory Findings
Mycobacterium
tuberculosis
HIV, from endemic region,
exposure history
Chronic cough, weight loss,
fevers, night sweats,
hemoptysis
Cavitation often occurs in the
apical and posterior
segments of the upper
lobes and superior
segments of lower lobes.
Solitary or multiple cavities
with thick, irregular walls
usually are present.
Positive TST or IGRA results
Positive sputum microscopy
and culture results
Nontuberculous
mycobacteria
Structural lung disease,
immunosuppressed
Chronic cough, hemoptysis,
fatigue, weight loss
Solitary or multiple
fibrocavitary changes and
nodules primarily in the
upper lobes
Sputum microscopy and
culture results Q21
Middle-aged to elderly women
without structural lung
disease
Chronic nonproductive cough
Typically involves the right
middle lobe and lingula
with nodules and
bronchiectasis
Also may see atelectasis,
consolidation with tree-in-
bud and ground-glass
opacities
Frank cavitation can occur
Sputum microscopy and
culture results
Chronic necrotizing
aspergillosis
Structural lung disease, inactive
or previously treated MTB,
prior lung resection, radiation
therapy, cystic fibrosis, or
lung infarction
Fevers, cough, dyspnea,
malaise, hemoptysis
Unilateral or bilateral
cavitary lesions in upper
lobes with adjacent pleural
thickening, which may
progress to form a
bronchopleural fistula
One-half of these cavities
can develop an
aspergilloma.
Positive for Aspergillus IgG
Positive sputum Aspergillus
PCR results
Histoplasmosis Ohio and Mississippi River
valleys, exposure to soil that
contains large amounts of bird
or bat droppings, chicken
coops, more common in those
with structural lung disease
Productive cough, fever, night
sweats, weight loss, erythema
nodosum, erythema
multiforme
Cavities can be solitary or
multiple, typically located
in the upper lobes and
associated with fibrosis.
Also may see punctate
calcifications in the spleen,
liver, and mesenteric
lymph nodes
Positive complement fixation
titers
Sputum fungal stain and
culture results Q22
Histoplasma antigen in
urine, blood, and BAL
Blastomycosis United States and Canada
surrounding the Ohio and
Mississippi River valleys and
the Great Lakes
More commonly affect the host
who is immunocompetentQ23
Cough, fever, night sweats,
malaise, skin and bone
involvement
Cavities are uncommon but
can be solitary or multiple,
typically located on the
upper lobes, and have thin
or thick walls.
Potassium hydroxide smear
of fresh sputum frequently
will indicate the organism.
Positive urine, serum, or BAL
antigens are helpful
Paragonimus Ingestion of raw freshwater crab
or crayfish
Endemic to Japan, China, Korea,
and the Philippines
Productive cough, chest pain,
back pain, fevers
Nodules with cavitation
Nodule size is most
commonly 2.0 cm.
Characteristic eggs at
sputum or BAL testing
Peripheral eosinophilia may
be seen.
(Continued)
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TABLE 3 ] (Continued)
Chronic Infection Patient Background Radiographic Findings Laboratory Findings
Echinococcus South America, countries
surrounding the
Mediterranean, the Middle
East, some sub-Saharan
African countries
Often asymptomatic for years,
may develop fevers, cough,
hemoptysis, wheezing,
anaphylaxis, or
pneumothorax
Majority of lesions are liver
cysts, but lung is involved
20%-30% of the time.
Pulmonary cavities may
form. Cavity wall may
calcify over time.
Collapsed laminated
membrane may float in the
cavity, producing the
water lily sign.
Serologic testing
Peripheral eosinophilia may
be seen.
Tracheobronchial
papillomatosis
Human papillomavirus, multiple
papillomas in the
nasopharynx, larynx, and
bronchial tree
Mucus plugging with finger-
in-glove appearance,
atelectasis, sold and
cavitary nodules
Nodules are 0.5-5 cm.
Bronchial tree tissue biopsy
IGRA ¼ interferon gamma release assay; MTB ¼ Mycobacterium tuberculosis; TST ¼ tuberculin skin test. See Table 2 for expansion of other abbreviation.
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to present primarily with signs of chronic airway
inflammation, including bronchiectasis and small
airway disease manifesting as branching centrilobular or
tree-in-bud opacities. Although these findings may
occur anywhere throughout the lung, a particularly
distinct pattern is the predominant involvement of the
lingula and middle lobe (Figs 14E-G). In more extensive
cases, frank cavitation may occur.78
Fungal Disease: CNA is an indolent, destructive process
due to Aspergillus species in the lung, which can be
differentiated from IPA because of its chronicity
(months to years).60 These patients will present with
fever, cough, sputum production, dyspnea, hemoptysis,
anorexia, weight loss, and malaise. Almost all patients
with CNA have underlying structural lung disease such
as COPD, inactive orpreviously treated TB, prior lung
resection, radiation therapy, cystic fibrosis, or lung
infarction.60,79 The most sensitive laboratory test is an
Aspergillus IgG antibody. With sputum, Aspergillus
polymerase chain reaction testing is more sensitive than
TABLE 4 ] Malignancy
Malignancy Patient Background
Primary Smoking history, family history of lung
cancer, and asbestos exposure
Cough, weight loss, malaise,
hemoptysis
Irregu
sign
Usual
pre
Metastatic Extrathoracic malignancy (commonly
squamous cell) and smoking history
Cough, weight loss, malaise,
hemoptysis
Multip
nod
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culture.80 Radiographically, Aspergillus manifests as
unilateral or bilateral cavitary lesions in the upper lobes
associated with adjacent pleural thickening, which may
progress to a bronchopleural fistula. Approximately
one-half of these cavities can develop an aspergilloma
(Fig 15).56,60,62,81,82
Histoplasmosis is caused by the dimorphic fungus
Histoplasma capsulatum. The fungus typically lives in
soil that contains large amounts of bird or bat
droppings. In the United States, Histoplasma is endemic
around the Ohio, Missouri, and Mississippi River valleys
and St. Lawrence River area.82 Patients with structural
lung disease such as COPD are at risk and typically will
have had symptoms of productive cough, malaise, fevers,
night sweats, and weight loss. Less common symptoms
include chest pain due to mediastinal lymph node
enlargement, arthralgias, arthritis, erythema nodosum,
and erythema multiforme.83 Positive complement
fixation titer and sputum fungal stain and culture results
and positive Histoplasma antigen in urine, blood, and
Radiographic Findings Laboratory Findings
lar internal wall and notch
ly solitary with an upper lobe
dominance
Tissue at histopathologic
examination
le bilateral pulmonary
ules, which can cavitate and
y from irregular and thick to
ular and thin
ee Cheerio sign
Tissue at histopathologic
examination
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TABLE 5 ] Autoimmune Disorders
Autoimmune Disorder Patient Background Radiographic Findings Laboratory Findings
Rheumatoid arthritis History or symptoms of
rheumatoid arthritis,
including joint pains and
fevers
Well-defined nodules of a
few millimeters to a few
centimeters with central
cavitation and sometimes
seen with the underlying
background of interstitial
lung disease
Elevated rheumatoid
factor level
Elevated anti-CCP
antibody level
Elevated ESR or CRP level
Granulomatosis with
polyangiitis
History of granulomatosis
with polyangiitis
May have symptoms
including rhinosinusitis,
epistaxis, fever, malaise,
hemoptysis
Multiple and bilateral
pulmonary nodules
Cavitation can occur in 25%-
50% of nodules that are
usually thick walled.
Elevated serum
cytoplasmic anti-
neutrophil antibodies
against protease 3 in
cytoplasmic granule
titers
Anti-CCP ¼ Anti-cyclic citrullinated peptide. See Table 2 legend for expansion of other abbreviations.
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BAL all support the diagnosis.84,85 Radiographically,
cavities typically are found in the upper lobes, and
associated fibrosis can be seen in up to 30% of patients
(Fig 16A).86-88 Findings of numerous punctate
calcifications in the spleen, liver, and mesenteric lymph
Figure 14 – A-G, Nontuberculous mycobacteria. Axial (A, B) and coronal (C)
nontuberculous mycobacteria demonstrating thick-walled cavities, bronchiect
right lower lobe. Coronal CT scan (D) demonstrates fibrocavitary disease in t
superiorly. Axial CT scans (E, F, G) demonstrate multiple thick-walled cavit
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nodes are particularly suggestive signs of previous
histoplasmosis (Figs 16B and 16C).89 In
contradistinction, although TB also may result in splenic
and hepatic calcifications, these are characteristically far
less numerous.
CT scans obtained in a 68-year-old woman with sputum culture-positive
asis, bronchial wall thickening, and several tree-in-bud opacities in the
Q26he lung apexes bilaterally, with traction of the hila and fissures (arrows)
ies confined to the right lung with tree-in-bud opacities bilaterally.
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Figure 15 – A-C, Aspergilloma. Axial CT scan (A) demonstrates solid masses in dependent positions within biapical cavities, consistent with fungus
balls. Bronchiectasis with aspergilloma (hematoxylin-eosin, �2 magnification). Image (B) shows a markedly dilated cavitary airway surrounded
by acute and chronic inflammation and a thick rim of fibrosis. This pathology slide is from a different patient from the radiographic image of
Figure 15A. Bronchiectasis with aspergilloma (Gomori methenamine silver, �20 magnification). Image (C) shows that within the airway lumen is a
fungus ball with the morphology of the Aspergillus species. The fungal organisms are highlighted by the Gomori methenamine silver stain. This
pathology slide is from a different patient from the radiographic image of Figure 15A.
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Figure 16 – A-C, Histoplasmosis. Axial high-resolution CT scan (A) demonstrates a thick-walled, cavitary nodule with eccentric calcification in the
right upper lobe. Coronal CT scan (B) obtained with a mediastinal window demonstrates large calcified lymph nodes in the right hilum and a thick-
walled, cavitary nodule (arrow Q27) with eccentric calcification in the right upper lobe. Coronal CT scan (C) obtained with a mediastinal window
demonstrates multiple punctate calcifications in the spleen.
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Blastomycosis is caused by Blastomyces dermatitidis and,
similar to Histoplasma and Coccidioides, lives in the soil,
particularly in moist soil. It typically is found only in the
United States and Canada surrounding the Ohio and
Mississippi River valleys and the Great Lakes.
Pulmonary blastomycosis occurs when the fungusfrom
the soil is inhaled.90 More commonly seen in a host who
is immunocompetent, these patients are often
asymptomatic. In those who develop symptoms, the
illness begins about 30 to 45 days after exposure, with
cough, fevers, night sweats, weight loss, and malaise
being common. Skin is the most common
extrapulmonary site of infection. It often begins with a
papulopustular lesion that progresses to ulcerative,
verrucous, or crusted lesions (Figs 17A and 17B). The
bone is the second most common extrapulmonary site of
infection, and most patients with osteomyelitis have
concomitant pulmonary blastomycosis.91 Patients may
have positive sputum smears; cultures; or urine, serum,
or BAL blastomycosis antigen.92,93 Radiographically,
cavitation occurs less frequently in blastomycosis than in
histoplasmosis and TB. Cavities can have thin or thick
walls, be single or multiple, are more commonly located
in the upper lobes (Fig 17C), and can result in
posttreatment scarring.94
Parasitic Diseases: Paragonimiasis is a food-borne
illness caused by the lung fluke Paragonimus
westermani and is associated with the ingestion of raw
freshwater crab or crayfish. The majority of cases occur
in Asia, although some cases have been acquired in the
United States.5,95 Productive cough, chest pain, back
pain, fever, and dyspnea are common; however, some
patients can be asymptomatic.96 At laboratory testing,
an elevated blood eosinophil count and visualization of
eggs on BAL can be seen.97,98 Radiographically,
Figure 17 – A-C, Photograph (A) shows two hyperkeratotic verrucous papules
discrete hyperkeratotic ovoid pink plaque (arrow) in a patient with cutaneou
current smoker with a history of diabetes with cavitary blastomycosis, demo
scattered, ill-defined, small air-space opacities throughout the lung, most pro
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nodules are common, with cavitation noted in 15% to
59% of cases.1 In one series, the most common nodule
size was 2 cm.99
Echinococcosis results from infection with Echinococcus
granulosus, a tiny tapeworm found in dogs (the
definitive hosts.) Echinococcosis is found in Africa;
Europe; Asia; the Middle East; Central and South
America; and, in rare cases, North America.97 Patients
are often asymptomatic for years; however, if signs or
symptoms develop, chest pain, cough, hemoptysis, or
pneumothorax are seen. Patients also may develop
wheezing, fever, urticaria, and anaphylaxis if antigenic
material is released from a cyst.99 Laboratory analysis
may reveal peripheral blood eosinophilia and positive
serologic test results.98,100 Radiographically, liver cysts
are the most common finding; however, 20% to 30% of
cases develop lung cysts. If air enters the ruptured cyst, it
can appear as a crescent-shaped lucency or have a
cavitary appearance. There also may be evidence of a
collapsed laminated membrane that may float in the
cavity, producing the water lily sign (Fig 18).36
Eventually, the cavity wall calcifies Q.1,100
Viral Infections: Human papillomavirus can cause
tracheobronchial papillomatosis. Chronic infection
with H papillomavirus may result in multiple
papillomas within the nasopharynx, larynx, or
tracheobronchial tree. Respiratory papillomas may
undergo malignant transformation to squamous cell
carcinoma in 3% to 5% of patients.101 Radiologic
features include mucous plugging with finger-in-glove
appearance, atelectasis, and solid cavitary nodules
(Fig 19). Diagnosis is made by means of transbronchial
biopsy.100,102 Pulmonary nodules range from 0.5 to
5 cm in size.103
(arrow Q28) in a patient with cutaneous blastomycosis. Photograph (B) shows
Q29s blastomycosis. Axial CT scan (C) obtained in a 53-year-old man, a
nstrates multiple cavitary lesions bilaterally, along with additional
minent in the upper lobes.
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Figure 18 – Axial high-resolution CT scan obtained in a 37-year-old
woman admitted for treatment of Echinococcus pneumonia demon-
strates a thick-walled cavity with collapsed laminated membrane—the
water-lily sign (arrow). There is dense consolidation anterior to the
cavity.
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Step 6: Malignancy
Cavities are found relatively frequently in primary lung
cancer, with an incidence of up to 11% on plain chest
radiographs104 and up to 22% on CT scans.105
Woodring et al106,107 suggested that the maximum wall
thickness of the cavity can help differentiate between
malignant and nonmalignant causes, with a maximum
wall thickness > 15 mm indicating malignancy in more
than 90% cases. However, these studies looked at plain
chest radiographs rather than CT scans. A more recent
study evaluating cavity maximum wall thickness on
chest CT scans did not find a difference between
malignant and nonmalignant causes; however, it
appeared that malignant cavities were more likely to
have an irregular internal wall (49% vs 26%) and have
an indentation of the outer wall of the cavity
(54% vs 29%) as compared with a benign cavity
Q17
Figure 19 – Axial CT scan demonstrates a thick-walled cavity with an
irregular nodular margin due to tracheobronchial papillomatosis.
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(Fig 20).108 There is an upper lobe predominance.109
Diagnosis is made by means of histopathologic testing.
The most common type of primary cavitary lung cancer
is non-small cell lung cancer, especially squamous cell
carcinoma (69%-81%).107,108 Adenocarcinomas, large
cell carcinomas, and small cell carcinomas are unlikely
to cavitate.72 Primary or secondary pulmonary
lymphoma has a broad spectrum of appearances,
including consolidation, masses, and cavitating
nodules.110
Pulmonary metastases, most often from squamous
primaries such as head and neck, cervical, skin, or
sarcomas, also may cavitate. The radiographic
morphology of these cavities varies from thick and
irregular to very smooth and thin, simulating a cyst.72,111
Rarely, metastatic disease leads to the Cheerio sign,
defined as multiple tiny cavitary nodules typically only a
few millimeters in size, most often associated with GI
malignancies (Fig 21).36
Step 7: Autoimmunity
Rheumatoid arthritis (RA) is a systemic autoimmune
disorder characterized by synovial inflammation,
auto-antibody production, cartilage and bony
destruction, and common pulmonary complications.112
Fifty percent to 80% of patients with RA will have a
positive rheumatoid factor, anti-cyclic citrullinated
peptide antibody, or both.113 Common pulmonary
findings include interstitial lung disease (ILD), pleural
disease, and rheumatoid nodules. Rheumatoid nodules
are found in 20% of patients and radiologically appear
as multiple well-defined nodules, a few millimeters to a
few centimeters in size. These nodules occasionally
develop central necrosis (Fig 22). A background of
underlying ILD may help with the diagnosis.114,115 A
variety of ILD patterns is seen on high-resolution CT
scans in RA; however, the usual interstitial pneumonia
pattern is seen most frequently (40%-62% of cases). In
usual interstitial pneumonia, high-resolution CT scans
show subpleural, basilar-predominant reticular
abnormalities with honeycombing and traction
bronchiectasis.6 Pleuraleffusions are noted in up to
70% of patients at autopsy; however, only 3% to 5% of
patients have symptoms.116 Because both RA and lung
cancer are associated with cigarette smoking, a cavitary
lung cancer always should be in the differential
diagnosis.
Granulomatosis with polyangiitis (GPA) is a systemic
autoimmune disease characterized by necrotizing
granulomatous inflammation and vasculitis of the upper
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Figure 20 – A-B, Squamous cell carcinoma of the lung. Axial (A) and coronal (B) CT scans demonstrate a thick-walled cavitary mass (arrows Q30) in the
left upper lobe. The internal walls of the cavity are irregular.
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Figure 21 – A-C, Axial (A) and sagittal (B) high-resolution CT scans obtained in a 36-year-old man with a history of autoimmune pancreatitis with a
diagnosis of metastatic adenocarcinoma of the pancreas demonstrate innumerable randomly distributed cavitary nodules with basilar predominance.
Axial PET/CT scan (C) through the lung bases. There is diffuse abnormal activity throughout both lungs, greatest in the lung bases. Biopsy results
helped confirm pulmonary metastatic disease from pancreatic cancer.
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http://chestjournal.org
Figure 22 – Axial CT scan obtained in a 45-year-old woman, a former
smoker with a 30-year history of rheumatoid arthritis and incidental
pulmonary nodules, demonstrates an irregular, lobulated, and spicu-
lated cavitary nodule in the left upper lobe. Surgical biopsy results helped
confirm a rheumatoid nodule.
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Figure 23 – A-C, High-resolution CT scan (A) obtained in a 73-year-old man
polyangiitis proved by means of pathologic testing demonstrates multiple bilat
right upper lobe has a dependent air-fluid level. Granulomatosis with polyan
lomatous lesion in a patient with clinical granulomatosis with polyangiitis. T
vasculitis. This pathology slide is from a different patient from the radiograp
magnification). Image (C) shows a cavitary granulomatous lesion in a patie
geographic necrosis surrounded by granulomatous inflammation. This patho
Figure 23A.
20 Special Features
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and lower respiratory tract and kidneys.117,118 Patients
with GPA can present with fever, malaise, night sweats,
anorexia, dyspnea, cough, purulent nasal discharge,
epistaxis, and hemoptysis.119 Anti-neutrophil
cytoplasmic antibody positivity occurs in up to 90% of
patients with severe systemic disease and in up to
78% with limited disease. Elevation of serum
cytoplasmic anti-neutrophil cytoplasmic antibody
against proteinase 3 titers frequently occurs in patients
with GPA and may be associated with disease
activity.7,120 Radiographically, multiple and bilateral
lung nodules are most common and occur in 40% to
70% of patients. Cavitation occurs in 25% to 50% of
these nodules and is more common in nodules > 2 cm
(Fig 23).120 Common associated findings include
evidence of chronic airway inflammation, manifesting as
focal or diffuse bronchial wall thickening and narrowing
or obstruction and bronchiectasis. Nonspecific foci of
parenchymal consolidation also are commonly seen.
Other diseases such as ankylosing spondylitis, primary
with a history of pyoderma gangrenosum and with granulomatosis with
eral cavitary masses and nodules. The larger, more anterior lesion in the
giitis (STAIN, �0 magnification Q31). Image (B) shows a cavitary granu-
his cavitary lesion is surrounded by granulomatous inflammation and
hic image in Figure 23A. Granulomatosis with polyangiitis (STAIN, �0
Q32nt with clinical granulomatosis with polyangiitis. This area shows
logy slide is from a different patient from the radiographic image in
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pulmonary amyloidosis, eosinophilic GPA, sarcoidosis,
and systemic lupus erythematosus rarely cause
pulmonary cavities and are beyond the scope of this
review.
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Conclusions
Diagnosing the cause of cavitary lung disease is a
challenge given the broad differential diagnosis and
varying manifestations. Significant advances have been
made in chest imaging with CT scanning, especially
increasing awareness of the wide variety of associated
findings identified in association with lung cavities.
Although imaging findings such as the halo sign,
reversed halo sign, peripheral nodules in varying stages
of cavitation, or an irregular internal wall constitute an
important component of our algorithm, radiographic
findings alone are usually insufficient for definitive
diagnosis. As a consequence, clinical context provides
critical clues and must be combined with the imaging
findings to narrow the differential diagnosis. We
propose this algorithm as a systematic approach to the
evaluation of cavities in the hope that it will provide an
efficient scheme for diagnosis and, ultimately,
appropriate therapy.
Acknowledgments
Financial/nonfinancial disclosures: None declared.
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	Cavitary Lung Diseases
	Algorithmic Approach
	Step 1: Are We Dealing With True Cavities?
	Step 2: Assess Disease Duration
	Step 3: Acute and Subacute Cavities (< 12 Weeks in Duration)
	Bacterial Pathogens
	Fungal Pathogens
	Step 4: Chronic Cavities (﹥ 12 Weeks in Duration)
	Step 5: Chronic Infections
	Mycobacterial Disease
	Fungal Disease
	Parasitic Diseases
	Viral Infections
	Step 6: Malignancy
	Step 7: Autoimmunity
	Conclusions
	Acknowledgments
	References