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The Radiologyof Primary Atypical Pneumonia

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The Radiologyof Primary Atypical Pneumonia Thorax: first published as 10.1136/thx.4.3.152 on 1 September 1949. Downloaded from Thorax (1949), 4, 152. THE RADIOLOGY OF PRIMARY ATYPICAL PNEUMONIA BY P. W. VERCG* From the Institute of Medical and Veterinary Science, Adelaide, and the Department of Experimental Medicine, University of Adelaide The pulmonary changes accompanying " primary appeared to lie peripherally in the lung and extension atypical pneumonia, aetiology unknown" have took place towards the hilum. been of considerable interest to radiologists and However, in the illness transmitted experimen- physicians over the past decade. Characteristic tally, pulmonary change became apparent from the varieties of pulmonary change occurring in this second to the fifth day after onset, and the earliest illness have been the subject of many reports in the sign was a local increase in the density of the lung literature, although few studies have been accom- markings without concomitant hilar involvement. panied by an adequate aetiological investigation. This was most commonly seen at the lung bases, This condition may be indistinguishable clinically best visualized by anterior-oblique films, and the from many other diseases which occur in both infiltration appeared either linear as an exaggeration epidemic and endemic form. Notable among these of the basilar truncal markings, or as patches of are infections with influenza virus A or B (Ziegler, soft irregular density. Frequently the latter were Curnen, and Mirick, 1947), infection with the located in the most peripheral and dependent psittacosis group of viruses (Treuting and Olson, portions of the lung, the costo-phrenic sulci, and copyright. 1944), " Q " fever (Feinstein, Yesner, and Marks, connexion with the normal hilar shadow did not 1946), infectious mononucleosis (Wechsler, Rosen- appear to be continuous. In the remaining patients blum, and Sills, 1946) and coccidioidomycosis perihilar infiltration with or without parenchymal (Rakofsky and Knickerbocker, 1946). Differentia- involvement was the earliest manifestation. tion is made, possibly by isolation of the causative Subsequently, in both the naturally occurring and agent, or by demonstration of a rise of titre in the the experimentally transmitted disease, in some http://thorax.bmj.com/ convalescent serum of antibody or certain other cases the infiltration remained limited to the peri- properties of the serum, or by the use of intra- pheral portions of one or both lower lobes, and the cutaneous sensitivity tests. hilar regions were not abnormal at any time, or the The investigations of the Commission on Acute early peribronchial infiltration appeared to spread Respiratory Diseases (1944), of Eaton, Meiklejohn, centrally toward the hilum with concomitant radial and van Herick (1945), and of the United States spread within the lower lobe; in others the perihilar Navy Research Unit at the Rockefeller Institute infiltration became increasingly apparent, and spread Hospital in New York (Curnen and others, 1945) occurred in the peripheral portion of one or more have confirmed, by the correlation of clinical, lobes in a fan shape, with the greatest density at the on September 27, 2021 by guest. Protected radiological, and aetiological investigations, the hilum. findings of many previous observers. In the Extraordinary variation in the density of the transmission to human volunteers of the naturally infiltration was noted, although usually it appeared occurring illness by inoculation of filtered throat soft and either granular or homogeneous. The lung washings and sputum, the Commission (1946) has markings were usually visible through the opacity, established a virus or viruses as the causative agent, although their outlines were frequently indistinct. and has provided a basis on which the radiological The borders of the areas of infiltration were com- study of the disease may be founded. monly ill-defined and irregular, fading into normal In these reports, the early radiological manifesta- lung tissue. The infiltration was rarely of sufficient tions in most cases of the naturally occurring disease density to resemble that of pneumococcal pneu- were stated to be an increase in size of one or both monia. Distinct but delicate " pencilling " at the hilar shadows, increasing perihilar infiltration, and site of the interlobar fissures frequently suggested extension of the shadow toward the periphery in the pleural involvement. Radiological features suggest- shape of a fan. Less commonly the early lesion ing an abnormal accumulation of pleural fluid were uncommon, and " plate-like " atelectasis was * This work was aided by a grant from the National Health and Medical Research Council of Australia. observed on occasions during convalescence. In Thorax: first published as 10.1136/thx.4.3.152 on 1 September 1949. Downloaded from THE RADIOLOGY OF PRIMARY ATYPICAL PNEUMONIA 153 most patients, the process appeared to be confined the radiological diagnosis distinguishing them from to a local area, most frequently to one of the lower pulmonary tuberculosis. Several of these reports, lobes, and in particular to one of the cardiophrenic where the clinical features were presented in sufficient angles. Spread of the lesion often occurred within detail, described in common with his own series a a lobe or in an adjoining lobe, and multiple lobe similar radiological picture, namely a gradual onset involvement was frequent. In some cases the lesion with predominantly constitutional symptoms, and a was confined to the hilar region. prolonged course with eventual complete resolution. Occasionally, the lesions lasted only a few days, Reiman (1938) reported a series of eight cases, but usually they progressed, and then underwent which presented a radiological picture and course slow resolution over a period of one to three weeks. strikingly similar to those of two of Scadding's Resolution was observed to occur in several ways. patients. All the patients were adults, and a mild In most instances it proceeded from the periphery infection of the upper respiratory tract was followed of the lung toward the hilum, but occasionally in by severe diffuse atypical pneumonia, and in two the reverse direction. Also progressive reduction in patients by encephalitis. the size and diminution in density of the affected Patients presenting similar radiological features, area was observed until no further evidence of with severe and prolonged illness, were reported by consolidation remained. In many instances, during Kneeland and Smetana in 1940. Such cases have the process of resolution, the affected area assumed since occurred, usually as a minority in epidemics of a diffusely mottled appearance. Frequently, after primary atypical pneumonia. McCarthy (1943) all the pulmonary involvement was thought to have noted that these patients were extremely ill. Lewis disappeared the broncho-vascular markings remained and Lusk (1944) reported such cases as a " broncho- prominent. The enlarged hilar shadows often alveolar phase," and suggested that the radiographic persisted for several weeks. manifestations could be explained pathologically by When the infiltration was mottled it occasionally small areas of atelectasis and alveolar exudation presented the intermingled with emphysematous areas. Showacre, appearance of small abscess cavities. copyright. Infiltrations radiating from the hilum with involve- Wightman, and Moore (1944) recorded their ment of the upper lobe resembled tuberculosis, experience with probable primary atypical pneu- whereas other lesions, especially in the lower lobes, monia over a decade, and emphasized that the simulated bronchiectasis. In several cases ofexperi- radiographic pattern varied from one season to mentally transmitted illness, the pulmonary opacities another and at times during the same season. were small, discrete, and nodular in the early stage, Eaton, Meiklejohn, and van Herick (1942, 1945) http://thorax.bmj.com/ later enlarging in size and becoming patchy and reported the isolation of a new virus from cases of confluent. This type of infiltration might resemble primary atypical pneumonia; they apparently miliary tuberculosis. transmitted an infectious agent to cotton rats from These observers have emphasized that other forms a fatal case of a very diffuse " miliary " pneumonia. of pneumonia could not be distinguished from Jamison (1945) recorded further cases of primary primary atypical pneumonia on the basis of radio- atypical pneumonia; in two patients the infiltration graphic evidence alone, and that a diagnosis of was of a finely nodular or patchy type, scattered primary atypical pneumonia was not justified unless uniformly in both lungs. Loffler and Moeschlin made in conjunction with clinical and laboratory (1946) reported a further series of seven such cases, on September 27, 2021 by guest. Protected findings. four of which were fatal. In the sera of three Of particular interest is that form of primary patients ofthe four tested, cold agglutinins developed. atypical pneumonia in which the pulmonary Most descriptions of this form of primary opacities resemble miliary tuberculosis. Scadding atypical pneumonia, with the exception of that of (1937) described four cases of " disseminated focal Scadding (1937), suggest that resolution is early and pneumonia " and was impressed by the resemblance complete. In his patients, resolution tended to be of the infiltration to tuberculosis. Radiological slow and irregularly delayed, and in one was not manifestations consisted of "
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