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MR Imaging of Pneumonia in
Immunocompromised Patients:
Comparison with Helical CT
Claudia C. Leutner 1 OBJECTIVE. A T2-weighted turbo spin-echo sequence was compared with CT in immu-
Jürgen Gieseke 2 nocompromised patients with opportunistic pneumonia.
Götz Lutterbey 1 SUBJECTS AND METHODS. Sixteen patients with pneumonia shown on helical CT
Christiane K. Kuhl 1 were examined using MR imaging within 2 days. MR examinations were performed on a 1.5-T
system with a transversal T2-weighted ultrashort turbo spin-echo sequence using expiratory gat-
Axel Glasmacher 3
ing and diastolic triggering. Two radiologists reviewed the MR and CT images independently.
Eva Wardelmann 4
The number, localization, and morphology of lesions were noted. MR image quality was rated
Albert Theisen 3 using a 4-point scale.
Hans H. Schild 1 RESULTS. The results of the CT and MR examinations concerning the number and morphol-
ogy of pulmonary lesions caused by pneumonia were identical in 75% of the patients (n = 12). MR
imaging was able to depict all typical features of pneumonia including different stages of paren-
chymal infiltration (ground-glass versus consolidation). MR imaging depicted early necrotizing
pneumonia not shown on contrast-enhanced CT in 25% of the patients (n = 4); 82% of the MR ex-
aminations were rated as excellent (1 point) or good (2 points).
CONCLUSION. T2-weighted turbo spin-echo imaging is able to depict characteristic fea-
tures of pneumonia and shows excellent results compared with CT. This MR technique offers ad-
vantages in patients with pneumonia because of its higher sensitivity for necrotizing pneumonia.

D
uring the last decade the interest in
MR imaging of the lung paren-
chyma has been growing. Al-
though a number of studies have shown that
MR imaging is able to depict a variety of pul-
monary diseases, the role of MR imaging in
the assessment of the lung needs to be ex-
plored further [1–5]. The major problems of
MR imaging of the lung result from the low
proton density of normal lung tissue and the
susceptibility artifacts that are caused by the
Received August 9, 1999; accepted after revision
extensive air–tissue interfaces of the paren-
January 4, 2000. chyma, with both factors leading to a low sig-
1
Department of Radiology, University of Bonn, Bonn, nal intensity of the pulmonary parenchyma
Germany. Address correspondence to C. C. Leutner, [6]. However, studies using T2-weighted turbo
Radiologische Klinik, Universität Bonn, Sigmund-Freud-Str. spin-echo sequences indicate a significant im-
25, 53127 Bonn, Germany.
2
provement of lung MR imaging regarding im-
Philips Medical Systems, Eindhoven, The Netherlands.
age quality and lesion detectability [7–9].
3
Department of Internal Medicine, University of Bonn, Despite the increasing interest in lung MR
53127 Bonn, Germany.
imaging, only a few studies compare MR imag-
4
Department of Pathology, University of Bonn, 53127 Bonn, ing of the lung parenchyma with helical CT [8,
Germany.
10, 11]. To our knowledge, no systematic study
AJR 2000;175:391–397
of MR imaging in patients with pneumonia has
0361–803X/00/1752–391 been published until now, although the evalua-
© American Roentgen Ray Society tion of MR imaging as an alternative to CT in
the diagnosis of pneumonia is of considerable
clinical interest: an increasing number of CT ex-
aminations are performed to rule out pneumo-
nia in immunocompromised patients because
studies indicate that the early diagnosis of op-
portunistic pneumonia leads to a significant
change in patient treatment [12, 13]. Therefore,
patients at risk for opportunistic pneumonia
may undergo repetitive CT examinations during
the course of illness. The aim of our study was
to find out how MR imaging compares with CT
regarding the depiction of typical features of
pneumonia and the detectability of lesions. For
this reason MR imaging and CT were com-
pared in immunocompromised patients with
typical findings of pneumonia in the initially
performed CT examination.
Subjects and Methods
Patients
This prospective study was performed from March
1997 until December 1998 and included all immuno-
compromised patients with a CT examination show-
ing typical findings of pneumonia. In our department,

AJR:175, August 2000 391


CT examinations are routinely performed in immuno-
compromised patients—in particular, in neutropenic
patients with persisting fever under antibacterial treat-
ment or with clinical signs of pneumonia (or both)
when chest radiographic findings are normal or sug-
gestive of early pneumonia. During the study time in-
terval, 51 immunocompromised patients were
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examined using CT. Sixteen CT examinations were
rated as showing normal findings, and 35 CT exami-
nations showed typical findings of pneumonia.
Unstable patients, minors, and patients with stan-
dard medical contraindications to MR examination
(e.g., a cardiac pacemaker) were excluded. Patients in
whom the CT and MR examination could not be per-
formed within 2 days were excluded too. This time
limit was chosen to avoid divergent results of MR
and CT examinations caused by rapid changes of
pulmonary infectious lesions during therapy. Be-
cause of these limitations 19 patients had to be ex-
cluded. Sixteen patients could be included in the
study (six women and 10 men; age range, 18–71
years; mean age, 46 years). Informed consent was
required from all patients. The study was approved
by our internal review board.
The diagnosis of pneumonia was established by
the typical clinical findings (e.g., fever, cough) and the
pathologic findings of the CT examination. The initial
chest radiograph in these patients showed normal
findings in five patients and was suggestive of early
pneumonia in 11 patients. In eight patients, a definite
diagnosis was made using bronchoscopy or biopsy.
Two patients died and the diagnosis was established at
autopsy. In four patients, a bacterial infection was as-
sumed because pneumonia resolved completely un-
der antibacterial therapy. In two patients, the causal
infectious organism remained unknown despite per-
cutaneous or open lung biopsy. However, clinical and
radiologic findings were highly suggestive of an inva-
sive pulmonary aspergillosis. The following infec-
tious pathogens were found: Aspergillus species in
five patients, Mycobacterium tuberculosis in two pa-
tients, Pneumocystis carinii in two patients, Geotri-
chum capitatum in one patient. All patients were
immunocompromised because of leukemia (n = 11),
AIDS (n = 4), or malnutrition (n = 1).
All surviving patients had clinical and radiologic
follow-up during antibacterial or antifungal treatment.
All patients including those with normal findings on a
chest radiograph showed typical findings of pneumo-
nia on the chest radiograph during the follow-up inter-
val. Both the symptoms of pneumonia and the
pathologic findings on the CT scan or chest radiograph
disappeared completely under antimicrobial treatment
in all surviving patients. Therefore, the pathologic
findings described in this article can definitely be as-
sumed to have been caused by infectious pneumonia.
MR Examinations
MR studies were performed with a 1.5-T MR im-
ager (NT Powertrak 1000; Philips Medical Systems,
Eindhoven, The Netherlands) using a body coil or a
dedicated surface coil (Synergy Coil; Philips Medical
Systems). The imaging protocol consisted of a trans-
versal T2-weighted ultrashort turbo spin-echo se-
392
Leutner et al.
quence, which is the standard T2-weighted sequence
for lung MR imaging in our department. The ul-
trashort turbo spin-echo sequence is a modified turbo
spin-echo sequence with an increased bandwidth of
the frequency-encoding gradient. It allows the applica-
tion of high turbofactors, thus leading to short echo-
spacing (7.5 msec). To compensate for respiratory and
cardiac motion, image acquisition was performed dur-
ing expiration (expiratory gating) and during the dias-
tolic heart phase (peripheral pulse measurement on the
right hand of the patient; 200-msec trigger delay to the
peak of the pulse wave). Depending on the respiration
frequency of the patient, the effective TR ranged from
2000 to 4000 msec and the TE was 90 msec. Twenty-
four slices with a slice thickness of 6 mm and an inter-
slice gap of 0.6 mm were acquired (field of view, 350
mm; matrix size, 256 × 192; number of excitations,
six). Spatial presaturation of the chest wall tissue was
used. The average scan time for this sequence was 10
min (multislice acquisition).
CT Examinations
All CT examinations were helical (Somatom 4A;
Siemens, Erlangen, Germany). Twelve CT examina-
tions were contrast-enhanced. In four patients, unen-
hanced CT was performed because the patient had
standard contraindications to contrast agents (e.g.,
renal failure). The helical CT scans were acquired
with a collimation of 8 mm, a longitudinal table
speed of 8 mm/sec, and image reconstruction inter-
vals of 8 mm. The images were viewed at window
settings for lung parenchyma and mediastinum.
Image Analysis
Two observers experienced in chest CT and MR
imaging reviewed the CT and MR images sepa-
rately. A decision for each MR or CT examination
was reached by consensus. The reviewers were
asked to assess the presence, number, and location
of pulmonary infiltrations or other pulmonary
pathologic findings including infiltrations of lung
parenchyma–like consolidations or ground-glass
infiltrations, nodular infiltrations, reticular infiltra-
tions, cystic disease and cavitation, or bullae. Ac-
cording to the standardized nomenclature defined
for parenchymal findings in CT, consolidation was
defined as a homogeneous increase in lung paren-
chyma attenuation (CT) or signal intensity (MR
imaging) that obscures the margins of vessels and
airway walls. Ground-glass infiltration was defined
as an opacity (CT) or hyperintensity (MR imaging)
not obscuring bronchovascular margins [14]. A
systematic study of the signal intensity of the MR
findings in comparison with that of other anatomic
structures, such as the fatty tissue of the chest wall,
was not performed. However, the reviewers were
asked to note signal variations within lesions—for
example, lesions consisting of a hypointense rim in
a hyperintense infiltration of the lung parenchyma.
This finding has been described in MR studies of
various anatomic regions and has been called the
“reverse-target” sign [10, 15–18]. This term also
will be used in our study. A reverse-target appear-
ance is a strong indicator for a necrotizing lesion or
an abscess according to the literature [10, 15–18].
For the contrast-enhanced CT scans, the following
criteria for image analysis were applied: solid en-
hancement; rimlike enhancement, indicating ne-
crotizing pneumonia; and no enhancement.
The consensus findings of the MR and CT exam-
inations were compared concerning the morphology,
the location, and the number of lesions. Findings
were rated for each patient as identical or divergent.
In the divergent cases, MR imaging and CT exami-
nations as well as follow-up examinations and histo-
logic proof were reviewed to determine which
imaging method was correct.
The MR images were assessed for quality (1, ex-
cellent [no artifacts]; 2, good [few artifacts]; 3, mod-
erate [of diagnostic value but impaired by artifacts];
4, poor [of no diagnostic value]). The causes of im-
paired quality were attributed to ghosting artifacts,
motion artifacts, patient movement artifacts, or a
combination thereof.
Results
MR Examinations
Pathologic findings were noted in all MR
examinations. The T2-weighted turbo spin-
echo sequence depicted the following lung
parenchyma findings: consolidations in eight
patients (50%), ground-glass hyperintensi-
ties in 10 patients (63%), nodules in 11 pa-
tients (69%), reticular infiltrations in four
patients (25%), cavities in two patients
(13%), and cystic disease in one patient (6%).
Ground-glass hyperintensities occurred al-
most always in combination with parenchy-
mal consolidation. In one patient (6%), the
reviewers noted bronchogenic spread of the
lesions along the vascular bundle (Fig. 1). Air
crescents were seen in one patient (6%). In
seven patients (44%), the reviewers noted a
reverse target–like appearance of lung le-
sions. Therefore, the reviewers rated these le-
sions as necrotizing pneumonia (16 lesions
and one patient with multiple reverse-target
lesions) (Table 1). Concerning the correlation
of MR findings with clinical findings, it was
remarkable that almost all patients with a sus-
pected necrotizing pneumonia had a proven
fungal infection, most of which were caused
by Aspergillus species (five patients).
The image quality of the transversal T2-
weighted ultrashort turbo spin-echo im-
ages was rated as excellent in six patients
(37%), good in seven patients (44%), and
moderate in three patients (19%). The
causes for reduced image quality were arti-
facts resulting from cardiac arrhythmia (n = 1)
or irregular respiration in a patient with
claustrophobia (n = 2).
AJR:175, August 2000
 MR Imaging and CT of Opportunistic Pneumonia

Fig. 1.—27-year-old man with pulmo-

nary tuberculosis and bronchogenic
spread.
A and B, MR image (A) and CT scan
(B) show small nodules (arrow, A)
and cavitation (arrowhead, A) in left
upper lobe.
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A B

TABLE 1 Comparison of CT and MR Imaging in Patients with Necrotizing Pneumonia

No. of “Reverse-Target” Lesions CT Findings

Patient No. Necrotizing Pneumonia Confirmed on Pathogen
Seen on MR Imaging Enhanced Unenhanced
1 3 Initial CT (3 lesions) Air crescent (3 lesions); Aspergillus species
enhancing rim (3 lesions)
3 Multiple Autopsy (all lesions) Solid enhancing nodules Aspergillus species
4 2 No definite confirmation; unenhanced Nodules Aspergillus species
CT performed as follow-up suspected
5 4 Follow-up CT (4 lesions) Solid enhancing nodules Aspergillus species
and consolidation
11 4 Follow-up CT (3 lesions) Nodules Geotrichum capitatum
15 2 Follow-up CT (2 lesions) Solid enhancing nodules Aspergillus species
suspected
16 1 Autopsy Solid enhancing nodule Aspergillus species

Correlation with CT Examinations
In all patients, both MR and CT examina-
tions showed identical results concerning the
number, the location, and morphology of pa-
renchymal infiltrations caused by pneumonia.
In one patient, CT showed additional findings
(bullae) not related to pneumonia. MR imag-
ing indicated necrotizing pneumonia in seven
patients (44%) because of the reverse-target
sign. Only one case had typical findings of ab-
scess formation seen on the corresponding CT
examination (Table 1). In six patients (38%),
CT did not reveal any sign of a necrotizing
pneumonia (contrast-enhanced CT in four pa-
tients and unenhanced CT in two patients).
Overall, more than 16 lesions with a reverse-
target appearance on MR images did not show
typical signs of a necrotizing pneumonia on
the corresponding CT scans (including one pa-
tient with multiple lesions).
To answer the question of which imaging
technique enabled correct diagnosis of necrotiz-
ing pneumonia, we took a look at follow-up ex-
aminations with CT (four cases) or at autopsy
results (two cases). We considered the MR diag-
nosis correct in all cases in which the typical
signs of necrotizing pneumonia in the question-
able lesions were depicted on follow-up CT
(e.g., rimlike enhancement, cavitation, and air
crescents) or in which histologic proof was
shown at autopsy. On the basis of these condi-
tions, the MR diagnosis was confirmed as cor-
rect in four cases (25%). Two cases were rated
as indeterminate because the initial CT exami-
nation was unenhanced, thus not allowing early
diagnosis of necrotizing pneumonia. However,
in one of these cases the diagnosis of necrotiz-
ing pneumonia was confirmed in three of four
lesions on follow-up CT performed after 2
weeks of antifungal treatment. In the other case,
a definite confirmation could not be established
because the follow-up CT examination was un-
enhanced. None of the patients without the re-
verse-target sign developed necrotizing
pneumonia within the follow-up time interval
until complete resolvement of pneumonia.
In conclusion, 75% of the MR and CT exam-
inations were rated as showing identical results
regarding lesions caused by pneumonia. This
included the two cases with suspected necrotiz-
ing pneumonia that were rated as indeterminate
because definite proof of necrotizing pneumo-
nia was not available. Twenty-five percent of the
MR examinations were rated as showing more

AJR:175, August 2000 393

 Leutner et al.

cases). In the remaining 11 patients with chest

radiographs suggestive of early pneumonia,
both CT and MR imaging showed more le-
sions than conventional radiographs in nine
patients, as shown in Figure 2. In three pa-
tients, chest radiographs showed nonspecific
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findings, whereas CT and MR imaging clearly

showed nodular infiltrations highly suggestive
of invasive pulmonary aspergillosis, as shown
in Figure 3.

Pathohistologic Correlation
In two patients, a correlation of reverse-tar-
get lesions with the autopsy findings was pos-
sible. The diagnosis of necrotizing pneumonia
was confirmed in all lesions (Table 1). In three
lesions, a complete pathologic workup was
performed. In the center of the lesions, a ne-
crosis was found consisting of cell detritus
and some hyphae. In two lesions, a pulmonary
artery running through the lesions was oc-
cluded by hyphae. The surrounding infiltra-
tion of the lung parenchyma consisted of
A inflammatory cells, a few hyphae, and blood
remnants including iron-laden macrophages.
The rim between central necrosis and sur-
rounding infiltration showed a high content of
fibrin. There was no considerable accumula-
tion of hyphae or hemosiderin- or iron-laden
cells in this rim.

Discussion
So far, MR imaging has played a minor
role in the assessment of lung parenchyma
compared with that of conventional chest radi-
ography and CT. The limitations of lung MR
imaging are well-known. Whereas motion ar-
tifacts due to physiologic motion can be re-
duced by respiratory and cardiac triggering or
gating, other problems closely related to the
complex anatomy of the lung remain. Arti-
B C facts caused by the susceptibility differences
between lung tissue and alveolar air and by
Fig. 2.—61-year-old woman with leukemia and biopsy-proven invasive pulmonary aspergillosis. the low proton density of the lung contribute
A, Chest radiograph obtained 1 day before CT and MR images shows unclear finding in left upper lobe that is sus-
pected to be early pneumonia. to the low signal intensity of normal lung tis-
B, MR image shows one of two lesions with “reverse-target” sign (arrow) in left upper lobe, indicating necrotiz- sue [19]. Nevertheless, a number of experi-
ing pneumonia. mental and clinical studies have shown that
C, Corresponding contrast-enhanced CT scan obtained 18 hr before B reveals dense consolidation but no sign of
necrotizing lesion. MR imaging is able to show pathologic find-
ings in a variety of lung diseases including
atelectasis, metastases, bronchogenic cancer,
accurate results than CT because of a higher or MR images, the following results underline hematoma, and fibrosis [1–5, 20–25]. This is
sensitivity for revealing necrotizing lesions. findings of previously published studies. In probably because of the substantially altered
five patients with normal findings on chest ra- condition of damaged lung tissue: the proton
Comparison of CT and MR Images with Chest diographs, CT and MR examinations showed density is increased by an exudative accumu-
Radiographs ground-glass hyperintensities, nodular infiltra- lation of water and cells and the susceptibility
Although it was not the major aim of our tions, or both (three cases each); consolida- effects are reduced, because this process leads
study to compare chest radiographs with CT tions (two cases); or a reticular pattern (two to the obliteration of the air space [19].

394 AJR:175, August 2000

 MR Imaging and CT of Opportunistic Pneumonia
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A B

Fig. 3.—71-year-old man with leukemia and multiple autopsy-proven

necrotizing lesions caused by invasive aspergillosis.
A, Chest radiograph obtained 1 day before CT and MR images shows le-
sions that are suggestive of early pneumonia in right lower lung.
B, MR image shows multiple lesions with “reverse-target” sign in right
lower lobe (arrows), indicating necrotizing pneumonia.
C and D, Contrast-enhanced CT scans at window setting for mediastinum (C)
and lung parenchyma (D) obtained immediately before B reveal all lesions as
solid enhancing nodules. There is no sign of necrotizing pneumonia.
C D

Although there are some well-known ad-
vantages of MR imaging (e.g., differentiation
of tumor and atelectasis), it is generally ac-
cepted that CT is the gold standard for the
assessment of pulmonary parenchyma. In
fact, only a few studies compare MR imag-
ing with CT—in particular, helical CT—in
an acceptable large patient group [9–11].
None of these studies showed any striking
advantage of using MR imaging over CT.
Therefore, CT remains the imaging method
of choice to assess the lung parenchyma.
The results of our study indicate that MR
imaging is able to show a variety of features
of opportunistic pneumonia already well-
known from CT including cavitation, air
crescents, cysts, and reticular infiltrations.
The same number of lesions was detected by
MR imaging and CT in all patients of our
study. In a number of cases, typical findings
were revealed—for example, bronchogenic
spread in pulmonary tuberculosis (Fig. 1).
Most of the CT and MR examinations
(75%) were rated as showing identical re-
sults concerning not only the number but
also the morphology of different lesions that
were due to opportunistic pneumonia. We
found it particularly interesting that MR im-
aging—just like CT—was able to depict dif-
ferent stages of infiltrations of the pulmonary
parenchyma, which are known as ground-
glass infiltration and consolidation. These
two terms represent precisely defined stages
of lung parenchyma infiltration based on the
visibility of the bronchovascular bundle, al-
though ground-glass opacities detected on

AJR:175, August 2000 395


helical CT with an 8-mm collimation proba-
bly represent less subtle parenchymal find-
ings than ground-glass opacities shown on
high-resolution CT.
Ground-glass infiltrations are known to be
a less severe form of parenchymal infiltration
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and a precursor of consolidation. Recent
studies comparing high-resolution CT and
chest radiography in immunocompromised
patients have shown that ground-glass infil-
trations may be an early sign of pneumonia
and are easily missed on chest radiographs
[12]. Furthermore, ground-glass opacities in
a specific distribution allow confident diag-
nosis of P. carinii pneumonia in HIV-positive
patients [26].
Our study shows that MR imaging is able
to depict and to show ground-glass infiltra-
tions and consolidations as well as helical
CT in patients with opportunistic pneumonia
(Fig. 1). However, there are some limitations
that are due to the design of our study. Our
major aim was to evaluate the potential of
MR imaging in depicting acute inflammatory
lesions. We did not establish the sensitivity
and specificity of MR imaging compared
with CT in detecting early pneumonia.
Therefore, the results of our study need to be
confirmed by studies with a larger number of
patients. In particular, the false-negative rate
of MR imaging has to be established because
there is a bias toward more extensive and se-
vere lung lesions caused by pneumonia in
this study. This bias results from the small
number of patients with ground-glass infil-
trations and the lack of comparison with
high-resolution CT, which is known to be
more sensitive to discrete lesions caused by
early viral or P. carinii pneumonia. In partic-
ular, the sensitivity of MR imaging regarding
ground-glass infiltrations detected on high-
resolution CT must be established. Concern-
ing the superiority of CT—as well as MR
imaging—to conventional chest radiography,
our study confirms the results of recently
published studies [12, 13] because a consid-
erable number of CT and MR examinations
showed pulmonary infiltrations in patients
with normal findings on chest radiography
(five of 16 patients in our study).
Furthermore, ground-glass infiltrations are
known to represent a number of pathohisto-
logic findings located in the alveolar space, in-
terstitial space, or a combination thereof.
Further studies need to determine whether MR
imaging is able to show subtle ground-glass in-
filtrations in diseases like fibrosis and sarcoido-
sis, which are mainly caused by an infiltration
396
Leutner et al.
of the pulmonary interstitium by inflammatory
cells. It is obvious that in most cases of pneu-
monia the alveolar disease with a high content
of protons predominates, which may be the
major reason for the good results in our study.
Regarding other definitely noninflammatory
findings like bullae, CT was superior to MR
imaging (one case in our study).
An interesting finding of this comparative
study is the possible impact on diagnostic strat-
egies in immunocompromised patients. Until
now, CT—in particular, contrast-enhanced
CT—has been the method of choice to estab-
lish a definite and early diagnosis of necrotiz-
ing pneumonia and abscess formation. In our
study, T2-weighted MR imaging was able to
depict necrotizing pneumonia earlier than CT
in 25% of all examinations. Regarding the pa-
tients with suspected necrotizing lesions, MR
imaging detected abscess formation earlier in
57% (four of seven patients suspected to have
necrotizing lesions). Although there is no defi-
nite proof of abscess formation in these patients
for the time of the MR examination (because of
severe bleeding risks preventing an invasive
procedure), we still believe that the MR diag-
nosis was sufficiently confirmed by findings of
follow-up CT examinations or histologic proof
from a subsequently performed biopsy. How-
ever, it is possible that the MR imaging de-
picted only a precursor of abscess formation
and not a fully developed abscess.
As a characteristic feature of necrotizing
pneumonia we observed the reverse-target
sign, which consists of a hypointense rim lo-
calized at the border between the central ne-
crosis and surrounding infiltration (both
showing high signal intensity). This sign has
already been described in the lung, brain, and
liver by other authors [15–18]. To the best of
our knowledge, there is no report in the litera-
ture until now connecting this sign with any
other infectious disease except necrotizing
pneumonia or abscess formation. Our study
indicates that regarding this issue unenhanced
T2-weighted MR imaging is superior to con-
trast-enhanced CT (Figs. 2 and 3). This is
probably because of the excellent soft-tissue
contrast of MR imaging.
Prior studies have proposed that the character-
istic features of the reverse-target sign result
from magnetic susceptibility effects of free radi-
cals in the abscess capsule or iron-laden mac-
rophages [17, 27]. In our study, we had the
ability to correlate the imaging findings with
pathohistologic findings in two cases. The strik-
ing feature in these two cases was a rim of fibrin
located at the border between the central necro-
sis and the surrounding inflammatory cell infil-
tration and hemorrhage. From the MR
appearance of other lesions with a considerable
content of fibrin (e.g., fibrinous pleuritis), it is
known that this substance is characterized by a
low signal intensity on T2-weighted imaging se-
quences. Any other explanation for the dark rim
of the reverse-target sign could not be found—in
particular, no rim of fungal hyphae or iron-laden
cells, both of which could also appear as areas of
low signal intensity on T2-weighted images. We
believe that a rim of fibrin is a plausible explana-
tion for the reverse-target sign because fibrin is a
ubiquitously found substance, whereas neither
iron-laden macrophages nor fungal hyphae oc-
cur in all the diseases connected with the re-
verse-target sign. Furthermore, it is unlikely that
a turbo spin-echo sequence would show suscep-
tibility artifacts that were due to production of
free radicals by macrophages because this MR
technique is otherwise known to be insensitive to
this kind of artifact.
In a healthy individual with necrotizing le-
sions in the lung, a wide range of possible
causes has to be considered including septic
emboli, infection with pyogenic bacteria, tu-
berculosis, noninfectious causes like Wege-
ner’s granulomatosis, and even metastases.
In the immunocompromised host—in partic-
ular, the patient with neutropenia—a nec-
rotizing pneumonia often represents a fungal
infection that is caused by Aspergillus spe-
cies or other fungi species. The early and
rapid development of necrosis is a specific
finding of invasive aspergillosis in neutro-
penic patients, which is caused by the angio-
invasive growth of Aspergillus species
leading to pulmonary infarctions [28]. In our
study, five of seven patients with a necrotiz-
ing pneumonia suffered from a fungal pneu-
monia mostly caused by Aspergillus species.
We believe that the reverse-target sign in the
lung is a characteristic sign for a necrotizing
pneumonia and may be a strong indicator of
a fungal pneumonia in neutropenic patients.
Recent studies in immunocompromised pa-
tients with fever of unknown origin advise
early high-resolution CT to exclude pulmo-
nary infection in these patients [12, 13]. The
diagnosis of a necrotizing pneumonia with
high-resolution CT is difficult and confined
to advanced stages of the disease during
which cavitation or air crescents are shown.
This study indicates that T2-weighted MR
imaging could be an alternative or at least a
valuable imaging method in addition to CT
in patients with pneumonia. However, this
statement applies only to the particular sub-
AJR:175, August 2000
 MR Imaging and CT of Opportunistic Pneumonia
set of immunocompromised neutropenic pa-
tients at whom our study was directed.
MR imaging of the lung has been the subject
of a number of studies during the past years. A
variety of imaging sequences and different
methods of motion compensation have been
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used. The latest studies indicate that T2-
weighted turbo spin-echo sequences are able to
compensate for the drawbacks of conventional
T2-weighted spin-echo sequences, which in-
clude a marked loss in signal intensity and ex-
tensive motion artifacts [3, 9, 11]. Our approach
to the motion compensation for lung MR imag-
ing is different from prior studies: we performed
a diastolic-triggered and expiratory-gated se-
quence. The image acquisition in the diastolic
heart phase substantially reduces pulsation arti-
facts. Furthermore, normal lung vessels up to
the subsegmental level are depicted with high
signal intensity that results from the marked re-
duction of the flow-void effect [8, 9]. This al-
lows exact localization of lung lesions because
the pulmonary vessels are the most important
“landmark” in the lung parenchyma. The major
factor contributing to the long scan time com-
pared with breath-hold T2-weighted techniques
described before is the expiratory gating, which
may cause a significant prolongation of the scan
depending on the respiratory frequency of the
patient. However, an MR examination with re-
peated breath-holds might fail to show pulmo-
nary lesions because of variable depths of
different breath-holds. Another problem is the
deterioration of image quality because of mo-
tion artifacts in patients who cannot hold their
breath as long and as often as necessary—obvi-
ously, a frequent condition in patients with lung
disease. For T2-weighted MR imaging, expira-
tory gating seems to be an acceptable resolution
for this problem. This is confirmed by the fact
that most MR examinations in this study were
rated as excellent or good regarding image qual-
ity and artifact reduction.
In conclusion, this comparison of helical
CT and T2-weighted turbo spin-echo imag-
ing in patients with opportunistic pneumonia
confirms the good results of this MR tech-
nique indicated by prior investigations [8, 9,
11]. In patients with opportunistic pneumo-
nia shown on standard helical CT, MR imag-
ing is able to depict lung lesions with almost
identical results as compared with CT. Typi-
cal features of pneumonia including different
stages of lung parenchyma infiltration could
be shown on MR imaging. Furthermore, the
early detection of a necrotizing lesion using
AJR:175, August 2000
the reverse-target sign offers advantages in
the immunocompromised host because this
sign is a strong indicator of a fungal pneu-
monia. However, further studies comparing
MR imaging with high-resolution CT are
needed to establish sensitivity and specificity
of MR imaging for early detection of oppor-
tunistic pneumonia.
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