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23
Radiographic
Findings
Neonatal
Pneumonia
Phillip J. Haney1
Mark Bohlman2
Chen-Chih
J. Suns
in
Although
morbidity
because
changes
membrane
resulting
pulmonary
infection
constitutes
a continuing
and significant
source of
and mortality
in the neonate,
radiographic
diagnosis
remains
difficult
of the wide range of nonspecific
changes
that can occur [1, 2]. These
often may mimic those of more benign
conditions,
such as hyaline
disease
and transient
respiratory
distress
syndrome
of the newborn,
in delayed
diagnosis
unless
strongly
suggestive
clinical
features
are
present.
In order
their relative
of 30 infants
Materials
Autopsy
researched
identified
and
9, 1983; accepted
after
revision
Department
of Diagnostic Radiology, University
of Maryland Hospital, 22 S. Greene St., Baltimore,
MD 21201. Address reprint requests toP. J. Haney.
2Depment
pitals,
Baltimore,
of Radiology,
Baltimore
City Hos-
MD 21224.
3Department
of Pathology, University
land Hospital, Baltimore, MD 21201.
of Mary-
the
spectrum
of expected
radiographic
analysis
changes
and
of the chest
films
Methods
the
only
significant
supporting
large
neonatal
referral
centers
were
pathologic
abnOrmality
was
evidence
of pneumonia.
Received
June
March 5, 1984.
to assess
incidences,
we undertook
a retrospective
with autopsy-proved
neonatal
pneumonias.
hyaline
membrane
or technically
suboptimal.
blood culture results were available only after death. Various degrees of respiratory
were present in all cases; apnea and bradycardia occurred in 66% of patients.
distress
HANEY
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24
Fig. 1.-Dense
bilateral alveolar infiltrates with air bronchograms and obof cardiac and diaphragmatic contours, at age 3 days. 6 hr before
death.
scuration
TABLE
1: Radiographic
Findings in Neonatal
ET AL.
Fig. 2.-Bilateral
than those
alveolar densities
less extensive
Pneumonia
No. (%)
Alveolar densities
Dense bilateralwith air bronchograms
Patchy bilateral
Right greater than left
Central, perihilar distribution
Air bronchograms
Pulmonary
interstitial
emphysema
Overinflation
Granular densities (hyaline membrane
disease)
Dilated vessels
Pneumothorax
Pleural effusion
Normal
Thickened
minor fissure
Pneumomediastinum
Bilateral reticular densities
23 (77)
10 (33)
3 (10)
(7)
1 (3)
15 (50)
7 (23)
5
4
3
3
3
3
3
1
1
(17)
(13)
(10)
(10)
(10)
(10)
(10)
(3)
(3)
Fig. 3.-Granular
densities with air bronchograms
brane disease, at age 3 days, 4 hr before death.
Results
The radiographic
findings
are listed in table 1 The most
common
abnormality
identified
was bilateral
alveolar densities, found in 77% of patients.
These were extensive
and
dense with air bronchograms
in 10 patients (33%) and were
less dense but bilateral and confluent
in 24% (figs. 1 and 2).
Bilateral
patchy,
segmental
densities
were found in three
patients
(10%). The alveolar
densities
were predominantly
right-sided
in two patients
and had a central, perihilar distnbution in one. Air bronchograms
were noted in one-half
of
NEONATAL
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Fig. 4.-A,
before death.
25
PNEUMONIA
Initial film on day 1 of life. Well inflated lungs with no other abnormalities.
of overinflation
inflation,
dilated vessels,
thickened
minor fissure,
air-space
filling, and pleural fluid produced
typical findings
of transient
tachypnea
of the newborn
in five patients
(17%) (fig. 4).
Bilateral fine reticular densities
were noted in one patient.
There were two unilateral
and one bilateral
pneumothoraces in the series. Complications
of mechanical
ventilation
patient management,
definitive radiographic
evidence of pneumonia would
be of considerable
value.
Unfortunately
the
previously
reported
changes
on chest film have shown
a
broad and varied spectrum
of abnormalities;
normal chest,
localized
or diffuse alveolar densities,
interstitial
lung disease,
and changes
identical
to hyaline membrane
disease
have all
been described
interstitial
patients
emphysema
of pulmonary
Three
Discussion
Despite
recent
advances
in therapy
of neonatal
infections,
pneumonia
remains a principal cause of death in the newborn,
with an incidence of 22%-23%
in unselected
infant autopsies
[3, 4]. Most pneumonias
result from an ascending
vaginal
infection
associated
with prolonged
labor and premature
rupture of the membranes,
although
the infection
occasionally
may be acquired
hematogenously
or during vaginal passage
[1 1 Premature
infants are affected
more often than full-term
infants. Symptoms
vary; the infant may be stillborn or manifest
immediate
severe
respiratory
distress
in some
cases,
whereas
in others
the only indication
of disease
may be
hypothermia.
Early diagnosis
requires
identification
of pathogenic organisms
in the amnion,
gastric aspirate,
or tracheal
aspirate.
Percutaneous
lung aspiration
also has been suggested
as a direct method
of establishing
the presence
of
].
infection,
but
requires
some
prior
localizing
not currently
used in our institutions.
Since early recognition
of these
information
infections
and
is critical
is
in
of our study
confirm
this
diversity
of radiographic
changes
in neonatal
pneumonia
but
also suggest
some helpful
patterns
of involvement.
Over
three-quarters
of cases showed bilateral alveolar densities as
the major radiographic
finding. The single most frequent
and
characteristic
pattern of alveolar change was that of a very
dense, bilateral
air-space
filling process
with numerous
air
bronchograms;
this was seen in 33% of our patients.
Most of
the remaining
cases with alveolar
densities
showed
milder
degrees
of involvement,
but again
with diffuse
bilateral
changes.
Three cases (1 0%) were less uniform,
with patchy,
segmental
densities
of the type seen in adult bronchopneumonia. Of interest are two cases in which alveolar involvement
was
predominantly
right-sided,
a pattern
analogous
to the
recently
described
right-sided
predominance
in some cases
of delayed
clearance
of fetal lung fluid [6]. Finally, a single
patient displayed
a central,
perihilar
distribution
of alveolar
densities
mimicking
pulmonary
edema.
A pattern of granular densities
with air bronchograms
indistinguishable
from hyaline membrane
disease
was noted in
four patients
(13%), precluding
a radiographic
diagnosis
of
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26
HANEY
ET AL.
221
2. Swischuk
LE. Radiology
of the newborn
and young infant, 2d
ed. Baltimore:
Williams & Wilkins, 1980:69-74
3. Benirschke
K. Routes and types of infectionin the fetus and the
newborn. Am J Dis Child 1960;99:714-720
4. Naeye RL, Dellinger WS, Blanc WA. Fetal and maternal features
of antenatal bacterial infections. J Pediatr 1971;79:733-739
5. Ablow RC, Gross I, Effmann
logic features
of early onset group B streptococcal
neonatal
sepsis. Radiology
1977;1 24:771-777
6. Swischuk LE, Hayden CK, Richardson
CJ. Neonatal opaque
right lung: delayed fluid resorption.
Radiology
1981;141 :671673
7. Leonidas JC, Hall AT, Beatty EC, Fellows RA. Radiographic
findingin early onset neonatal gruop B streptococcal septicemia.
Pediatrics
1977;59: 1006-1011