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CT Findings of Pneumonia After

Lung Transplantation
Jannette Collins 1 OBJECTIVE. The purpose of this study was to describe the CT findings of pneumonia in
Nestor L. Müller 2 patients who had undergone lung transplantation and to determine if specific imaging features
Ella A. Kazerooni 3 existed for the different infectious organisms.
Giuseppe Paciocco 3 MATERIALS AND METHODS. The authors retrospectively reviewed the medical
records of 262 patients with transplanted lungs at two lung transplantation centers. Patients
with a documented pneumonia and correlating abnormal findings on CT (39 patients with 45
pneumonias) were included in the study.
RESULTS. Of 45 pneumonias, Cytomegalovirus (n = 15), Pseudomonas (n = 7), and As-
pergillus (n = 8) organisms were the most common single responsible infectious agents. The
most common CT findings of pneumonia consisted of consolidation (n = 37; 82%), ground-
glass opacification (n = 34; 76%), septal thickening (n = 33; 73%), pleural effusion (n = 33;
73%), and multiple (n = 25; 56%) or single (n = 2; 4%) nodules. No significant difference in the
prevalence of findings was revealed among bacterial, viral, and fungal pneumonias ( p > .05, chi-
square test). Of 25 pneumonias in patients with a single transplanted lung, parenchymal abnor-
malities involved both lungs in 12 (48%), only the transplanted lung in 11 (44%), and only the
native lung in two (8%).
CONCLUSION. The manifestations revealed on CT of bacterial, viral, and fungal pneu-
monia after lung transplantation are similar, consisting of a combination of consolidation,
ground-glass opacification, septal thickening, pleural effusion, or multiple nodules. Therefore,
these findings cannot be used to suggest the infectious organisms in this patient population.

L ung transplantation is widely ac-

cepted as therapy for certain
forms of end-stage lung and pul-
monary vascular disease and is associated
transplantation and to determine if any im-
aging features are specific for the different
infectious organisms.

with a 71% 1-year and a 45% 5-year actuar-

Received January 11, 2000; accepted after revision
February 16, 2000.
Presented at the annual meeting of the American
Roentgen Ray Society, Washington, DC, May 2000.
1
Department of Radiology, University of Wisconsin
Hospital and Clinics, E3/311 Clinical Science Center,
600 Highland Ave., Madison, WI 53792-3252. Address
correspondence to J. Collins.
2
Department of Radiology, University of British Columbia
Hospital and Health Sciences Centre, Vancouver Hospital
and Health Sciences Centre, Heather Pavilion, 855 W. 12th
Ave., Vancouver, B.C., Canada V5Z1M9.
3 CT findings (e.g., acute rejection, severe graft dys-
Department of Radiology, University of Michigan Medical
Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-
0326.
AJR 2000;175:811–818
0361–803X/00/1753–811
© American Roentgen Ray Society
ial survival [1]. Infection is the most com-
mon cause of perioperative mortality and the
second most common cause of late mortality
(beyond 90 days) after lung transplantation
[2]. Opportunistic infection occurs in 34–
59% of all patients after lung transplantation
[3]. Chest radiographic findings in patients
with new opportunistic pneumonia may be
normal or abnormal; when abnormal, the
findings are usually nonspecific [4, 5]. CT
findings are often abnormal in lung trans-
plant recipients with pneumonia, and these
findings better show the morphology and
distribution of disease than chest radio-
graphs. The purpose of this study was to
characterize the abnormal findings seen on
CT in patients with pneumonia after lung
Materials and Methods
Medical records of all patients who underwent
lung transplantation at the University of Wisconsin
(n = 124) and the University of Michigan (n = 138)
between 1988 and 1998 were reviewed. In cases in
which pneumonia was documented, the radiology
records were reviewed to identify all patients with a
correlating abnormal finding on CT. CT was ordered
as part of a routine protocol or to evaluate new abnor-
mal findings identified on a chest radiograph. Patients
were excluded if they had a complication in addition
to pneumonia that interfered with the interpretation of
function, pulmonary hemorrhage, bronchiolitis oblit-
erans organizing pneumonia). Patients with CT
findings that were interpreted as normal or stable
were excluded from the study. Abnormalities in the
native lung related to the underlying disease were not
attributed to pneumonia. This selection technique re-

AJR:175, September 2000 811

 Collins et al.

sulted in a study group of 39 patients (19 from Uni-
versity of Michigan and 20 from University of
Wisconsin) with single (n = 23) and bilateral (n = 16)
transplanted lungs and 45 pneumonias.
Patients ranged in age from 18 to 67 years (mean
age, 45 years) at time of CT scanning. Twenty-three
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collimation at 10-mm intervals) through the bronchial
anastomoses without IV contrast material (n = 25),
helical CT (10-mm collimation at 10-mm intervals)
with IV contrast material (n = 3), high-resolution CT
(1.5-mm collimation at 10-mm intervals) without IV
contrast material (n = 9), high-resolution CT (1-mm
Frequency of CT findings for bacterial, viral, and fun-
gal pneumonias was evaluated with a chi-square test.
Results
Forty-five episodes of pneumonia in-

patients (51%) were women and 19 patients (49%)
were men. Underlying pulmonary diseases leading to
transplantation included emphysema (n = 22, includ-
ing eight with alpha1-antitrypsin deficiency), cystic fi-
brosis (n = 7), pulmonary fibrosis (n = 5),
Eisenmenger’s syndrome (n = 3), primary pulmonary
hypertension (n = 1), and sarcoidosis (n = 1). All infec-
tious episodes were documented by one or more of the
following methods: bronchoalveolar lavage (n = 16),
bronchoscopic biopsy (n = 14), sputum culture (n = 6),
autopsy (n = 1), bronchoalveolar lavage and biopsy
(n = 5), bronchoalveolar lavage and sputum culture
(n = 2) and bronchoalveolar lavage, biopsy and sputum
culture (n = 1). Cytomegalovirus (CMV) pneumonia
was diagnosed by laboratory findings of characteristic
inclusion bodies in material obtained at bronchoscopy
or autopsy or by a positive respiratory culture and his-
topathologic evidence of interstitial pneumonia. Diag-
nosis of bacterial infection was based on a positive
culture of sputum or bronchoscopic aspirate, often
combined with a positive blood, lung tissue, or pleural
fluid culture. Fungal infection was diagnosed from
culture and histologic evidence of tissue invasion.
CT was performed with a variety of protocols, in-
cluding high-resolution CT (1-mm collimation at 10-
mm intervals) combined with helical scanning (5-mm
collimation at 10-mm intervals) without IV contrast
material (n = 1), helical CT (10-mm collimation at
10-mm intervals) without IV contrast material (n = 5),
helical CT (5-mm collimation at 10-mm intervals)
without IV contrast material (n = 1), and helical CT
(5-mm collimation at 10-mm intervals) with IV con-
trast material (n = 1). All CT was performed between
0 and 7 days of documentation of the infectious epi-
sode (mean time, 5 days). No patient underwent anti-
microbial therapy more than 5 days before CT.
CT findings were reviewed for the presence of
nodules (single or multiple, size, margins, zonal dis-
tribution, halo sign of a surrounding area of ground-
glass attenuation, cavitation), areas of consolidation
(lobar distribution, cavitation), ground-glass opaci-
fication (lobar distribution), septal thickening, pleu-
ral effusion, thickening or enhancement of the
pleura, enlarged hilar or mediastinal lymph nodes
(<1 cm in short-axis dimension), and bronchial
anastomotic complication (stricture, dehiscence, en-
doluminal debris).
CT findings were initially interpreted by the col-
laborating chest radiologist (who had access to the pa-
tient history) at the home institution and subsequently
by one other chest radiologist. In the few instances of
interobserver disagreement, a consensus was reached.
cluded 16 bacterial, 15 viral, eight fungal,
one mycobacterial, and five mixed (Table 1).
No statistically significant differences be-
tween bacterial, viral, and fungal pneumo-
nias were found regarding frequency of
nodules, consolidation, ground-glass opacifi-
cation, septal lines, and pleural effusion on
CT (p > .05) (Table 2).
Bacterial Pneumonia
Of 16 bacterial pneumonias (Table 2), infec-
tious organisms included Pseudomonas (n = 7),
Staphylococcus (n = 3), and one each of Strep-
tococcus, hemophilus, gram-positive cocci not
otherwise specified, gram-negative cocci not
otherwise specified, Legionella, and combined
Pseudomonas and Staphylococcus.
Seven (44%) of 16 pneumonias had multiple
nodules with diameters of 1–3 mm (n = 4), 4–
10 mm (n = 2), or 1–3 cm (n = 4) on CT. One
mass (>3 cm) was revealed. Three pneumonias
had a combination of differently sized nodules.
Nodule margins were irregular (n = 6) or both
smooth and irregular (n = 1). Three pneumonias

TABLE 1 Frequency of Pneumonia Type for Each Underlying Pulmonary Disease (45 Pneumonias in 39 Patients)

Patients
Type of Disease Bacterial Viral Fungal Mycobacterial Mixed Total
No. %
Emphysema 14 36 9 9 3 1 5 27
Cystic fibrosis 7 18 3 2 3 0 0 8
Fibrosis 5 13 2 2 1 0 0 5
Eisenmenger’s syndrome 3 8 1 1 1 0 0 3
Pulmonary hypertension 1 3 1 0 0 0 0 1
Sarcoidosis 1 3 0 1 0 0 0 1
Total 39 16 15 8 1 5 45

TABLE 2 Frequency of CT Findings In Patients with Various Pneumonia Infections

Mycobacterial
CT Findings Bacterial (n = 16) Viral (n = 15) Fungal (n = 8) Mixed (n = 5) Total (n = 45)
(n = 1)
Nodules 7 (44) 9 (60) 7 (88) 1 (100) 3 (60) 27 (60)
Consolidation 15 (94) 10 (67) 6 (75) 1 (100) 5 (100) 37 (82)
Ground-glass 13 (81) 10 (67) 7 (88) 0 (0) 4 (80) 34 (76)
opacification
Septal lines 13 (81) 11 (73) 5 (63) 1 (100) 3 (60) 33 (73)
Pleural effusion 12 (75) 10 (67) 5 (63) 1 (100) 5 (100) 33 (73)
Lymph node 2 (13) 0 (0) 0 (0) 1 (100) 0 (0) 3 (7)
enlargement
Note.—Numbers in parentheses are percentages.

812 AJR:175, September 2000

 CT Findings After Lung Transplantation

had branching nodular and linear opacities
(“tree-in-bud” pattern) (Figs. 1 and 2), three had
a halo of ground-glass opacification surround-
ing the nodules, and one had nodule cavitation.
Fairly equal upper lung zone (apex to carina),
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Ground-glass opacification was seen in 13
(81%) of 16 pneumonias and involved all
lobes fairly equally (12 right upper lobe, 11
right middle lobe, 13 right lower lobe, seven
left upper lobe, and 10 left lower lobe), with
Eight (50%) of 16 pneumonias had con-
solidation and ground-glass opacification;
four (25%) had nodules, consolidation, and
ground-glass opacification; two (13%) had
nodules and ground-glass opacification; one

middle lung zone (carina to inferior pulmonary
veins), and lower lung zone (below inferior pul-
monary veins) distribution was shown.
Consolidation was present in 15 (94%) of
16 pneumonias predominantly in the right
middle lobe (n = 7), right lower lobe (n =
12), and left lower lobe (n = 9). Only two
cases involved the right upper lobe and three,
the left upper lobe. Nine pneumonias had
consolidation involving more than one lobe
(Fig. 3). The consolidation was unilateral in
eight pneumonias, bilateral in seven, and
when bilateral, usually asymmetric (n = 4).
12 pneumonias having more than one lobe
involved (Fig. 4). Ground-glass opacification
was unilateral (n = 5) or bilateral (n = 9),
with bilateral involvement asymmetric (n =
5) or symmetric (n = 4).
Thirteen (81%) of 16 pneumonias had
septal thickening, subjectively graded as
mild (n = 6) or extensive (n = 7) (Fig. 5).
Twelve (75%) of 16 pneumonias had pleural
effusions (11 right, 11 left, and 10 bilateral),
one had thick or enhancing pleura, and two
had enlarged hilar (n = 1) or mediastinal (n =
1) lymph nodes.
(6%) had nodules and consolidation; and one
(6%) had consolidation alone. Of the seven
cases of bacterial pneumonia involving a sin-
gle transplanted lung, four (57%) involved
the transplanted lung only, three (43%) in-
volved both lungs, and none involved only
the native lung (Table 3).
Viral Pneumonia
All 15 cases of viral pneumonia (Table 2)
were caused by CMV. Nine pneumonias (60%)
were associated with nodules on CT that were
multiple in eight and single in one. Nodule size

Fig. 1.—Pseudomonas pneumonia in 33-year-old man
who underwent bilateral lung transplantation for cystic fi-
brosis 3 years earlier. High-resolution CT scan shows ar-
eas of consolidation and ground-glass opacification in
right middle lobe. Note “tree-in-bud” opacities (arrow ) in
periphery of right lower lobe.
Fig. 2.—Gram-negative cocci pneumonia in 58-year-old
woman who underwent right lung transplantation for pul-
monary emphysema 4 months earlier. High-resolution CT
scan shows focal ground-glass opacification (large
arrow ) in right middle lobe and “tree-in-bud” opacities
(small arrows ) in right lower lobe.
Fig. 3.—Pseudomonas pneumonia in 29-year-old
man who underwent bilateral lung transplantation
for cystic fibrosis 1 year earlier. High-resolution CT
scan shows multifocal areas of consolidation and
ground-glass opacification in right middle, left up-
per, and both lower lobes. Bilateral pleural effu-
sions extend into major fissures. Mild septal
thickening (arrows) is seen in right middle lobe.
Lower lobe bronchi are dilated.

A B

Fig. 4.—Staphylococcus aureus pneumonia in Fig. 5.—Pneumonia caused by legionella organisms in 32-year-old woman who underwent right lung transplantation for
40-year-old man who underwent bilateral lung primary pulmonary hypertension 3 months earlier.
transplantation for alpha1-antitrypsin defi- A and B, High-resolution CT scans show diffuse extensive septal thickening and scattered ground-glass opacities in
ciency 1 year earlier. High-resolution CT scan right upper, middle, and lower lobes. Only transplanted lung was involved.
shows bilateral patchy areas of ground-glass
opacification, consolidation, mild septal thick-
ening, and bilateral small pleural effusions.

AJR:175, September 2000 813


was 1–3 mm (n = 7), 4–10 mm (n = 3), and 1–3
cm (n = 2). Two pneumonias had nodules of
more than one size (Fig. 6), and one had nod-
ules associated with branching linear opacities
(tree-in-bud appearance). Fairly equal zonal
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distribution of nodules was noted.
Ten (67%) of 15 pneumonias had consoli-
dation involving the right upper lobe (n = 5),
right middle lobe (n = 4), right lower lobe
(n = 5), left upper lobe (n = 3), left lower
lobe (n = 5), or more than one lobe (n = 6).
Involvement of Lungs in Patients Undergoing Single Lung Transplantation
TABLE 3
and Having Various Types of Pneumonia Infections
Type of Infection Native Lung Transplanted Lung
Bacterial 0 (0)
Viral 1 (9)
Fungal 1 (33)
Mixed 0 (0)
All 2 (8)
Note.—Numbers in parentheses are percentages.
Fig. 6.—Cytomegalovirus pneumonia in 57-year-old
woman who underwent right lung transplantation for
pulmonary emphysema 3 months earlier. CT scan
(10-mm collimation) shows several well-circum-
scribed nodules of various size in right middle and
lower lobes. Only transplanted lung was involved.
814
Collins et al.
The consolidation was unilateral in seven Eleven (73%) of 15 pneumonias had septal
and bilateral in three. When bilateral, consol- thickening that was mild in seven and exten-
idation was always asymmetric. sive in four (Fig. 7). Ten (67%) of 15 pneu-
Ten (67%) of 15 pneumonias had areas of monias had pleural effusions (eight right, five
ground-glass opacification involving the right left, and three bilateral). Thick or enhancing
upper lobe (n = 7), right middle lobe (n = 8), pleura was seen in three and right bronchial
right lower lobe (n = 7), left upper lobe (n = 4), anastomotic stenosis was seen in one.
left lower lobe (n = 6), or more than one lobe Four (27%) of 15 pneumonias had nod-
(n = 8). Unilateral involvement was seen in ules and ground-glass opacification; three
five, and bilateral involvement in five, of which (20%) had both consolidation and ground-
four were asymmetric and one symmetric. glass opacification; three (20%) had nodules,
consolidation, and ground glass opacifica-
tion; three (20%) had consolidation only;
one (7%) had nodules and consolidation; and
one (7%) had nodules only. Of 11 cases in-
volving a single transplanted lung, only the
Both Lungs Total transplanted lung was involved in six (55%),
4 (57) 3 (43) 7 both lungs in four (36%), and only the native
6 (55) 4 (36) 11 lung in one (9%) (Table 3).
0 (0) 2 (67) 3
Fungal Pneumonia
1 (25) 3 (75) 4
All eight cases of fungal pneumonia (Table
11 (44) 12(48) 25
2) were caused by Aspergillus organisms.
Seven (88%) of eight pneumonias had nod-
ules that were multiple (n = 6) or single (n =
1) (Fig. 8). The nodules varied in size from 1–
3 mm (n = 4), 4–10 mm (n = 3), and 1–3 cm
(n = 3); and one patient had a mass (>3 cm).
Three patients had nodules of more than one
size. The nodules had irregular (n = 6),
smooth (n = 1), or both smooth and irregular
(n = 1) margins. The tree-in-bud pattern was
seen in one case of pneumonia. Two cases had
nodules with cavitation (Fig. 9). A fairly equal
distribution of upper, middle, and lower lung
zone involvement was seen with all three
zones involved in five of the eight cases.
Six (75%) of eight pneumonias had consoli-
Fig. 7.—Cytomegalovirus pneumonia in 57-year-old dation that involved predominantly the lower
woman who underwent right lung transplantation for lobes (six right lower lobe, three left lower lobe,
pulmonary emphysema 7 months earlier. High-resolution
and one each of right upper, right middle, and
CT scan shows ground-glass opacification and exten-
sive septal thickening in right upper and lower lobes. left upper lobes). Three pneumonias had consoli-
Only transplanted lung was involved. dation involving more than one lobe. Consolida-
Fig. 8.—Aspergillus pneumonia in 47-
year-old man who underwent left lung
transplantation for pulmonary emphy-
sema 1 year earlier. CT scan (10-mm
collimation) shows well-circumscribed
nodule in periphery of right upper lobe.
Only native lung was involved.
Fig. 9.—Aspergillus pneumonia in 48-
year-old man who underwent right lung
transplantation for Eisenmenger’s syn-
drome 9 months earlier. CT scan (10-
mm collimation) shows thick-walled
cavitary mass in left lower lobe. Only
native lung was involved.
8 9
AJR:175, September 2000
 CT Findings After Lung Transplantation

tion was unilateral in three and bilateral in three.
Bilateral involvement was always asymmetric.
Seven (88%) of eight pneumonias had
ground-glass opacification that involved all
lobes fairly equally (four right upper lobe, three
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findings showed multiple 1- to 3-mm nod-
ules with smooth margins in a subpleural
distribution in the right upper, middle, and
lower lung zones; focal consolidation in the
right lower lobe (Fig. 11); mild septal thick-
6], which is higher than the frequency of in-
fection in other organ transplant populations.
In the lung transplant patient population, res-
piratory infection may progress rapidly to
respiratory failure and death [7–9]. In one

right middle lobe, six right lower lobe, four left
upper lobe, and four left lower lobe) (Fig. 10).
Ground-glass opacification was unilateral (n =
2) or bilateral (n = 5), and when bilateral was
symmetric (n = 2) or asymmetric (n = 3).
Five (63%) of eight pneumonias had sep-
tal thickening that was mild in four and ex-
tensive in one. Five pneumonias had pleural
effusions (three right, four left, and two bilat-
eral), and one had right bronchial anasto-
motic stenosis.
Five (63%) of eight pneumonias had a com-
bination of nodules, consolidation, and ground-
glass opacification; one (13%) had nodules and
ground-glass opacification; one (13%) had
nodules only; and one (13%) had consolidation
and ground-glass opacification. Of three cases
involving a single transplanted lung, only the
native lung was involved in one (33%), and
both lungs in two (67%) (Table 3).
Mycobacterial Pneumonia
One patient with bilateral transplanted
lungs had mycobacterial disease caused by
Mycobacterium tuberculosis (Table 2). CT
ening; small right pleural effusion; and
right hilar and mediastinal lymph node en-
largement.
Pneumonia of Mixed Cause
Five cases of mixed pneumonia (Table 2)
included fungal and bacterial (n = 3), bacterial
and viral (n = 1), and fungal and viral (n = 1).
Three (60%) of five pneumonias had nodules,
five (100%) had consolidation, and four (80%)
had ground-glass opacification. CT findings
showed septal thickening in three (60%, two
mild, one extensive), pleural effusions in five
(100%, five right, five left, and four bilateral),
left bronchial anastomotic stenosis in one, and
debris or exudate in subsegmental bronchi in
one (Fig. 12). Of four cases involving a single
transplanted lung, only the transplanted lung
was involved in one (25%), and both lungs in
three (75%) (Table 3).
Discussion
The prevalence of infection after isolated
lung transplantation can be as high as 59% [3,
study, infectious events accounted for 26% of
acute life-threatening complications in a se-
ries of 70 patients after lung transplantation
[10]. Two patients died as a direct result of in-
fectious complications. The reasons for the
high frequency of respiratory infection in the
lung transplant population include impaired
mucociliary transport in the denervated lung,
altered phagocytosis in alveolar macro-
phages, direct communication of the lungs
with the atmosphere, loss of cough reflex, and
interrupted lymphatic drainage [3, 11–14]. In
addition, airway anastomotic complications
may increase the rate of bacterial pneumonia
related to either impaired clearance of secre-
tions or the need for frequent procedures to
place or examine stents [15]. The trans-
planted lung is affected more often by infec-
tion than the native lung, presumably because
of impaired mucociliary function and cough
reflexes [3].
The widespread institution of antibiotic pro-
phylaxis and careful manipulation of immuno-
suppressive drugs have greatly decreased
perioperative infection-related morbidity. An-

Fig. 10. —Aspergillus pneumonia in 33-

year-old man who underwent bilateral
lung transplantation for cystic fibrosis 3
years earlier. High-resolution CT scan
shows patchy ground-glass opacifica-
tion and consolidation in right lower
lobe.

Fig. 11.—Tuberculous pneumonia in

46-year-old woman who underwent
bilateral lung transplantation for
alpha1-antitrypsin deficiency 4
months earlier. High-resolution CT
scan shows consolidation with air
bronchograms in right lower lobe.
10 11

Fig. 12.—Mixed pneumonia in 47-

year-old man who underwent bilat-
eral lung transplantation for pulmo-
nary emphysema 2 months earlier.
A and B, High-resolution CT scans
show patchy consolidation with air
bronchograms and endobronchial
debris (arrows ) in right lower lobe.
Sputum cultures grew Escherichia
coli, Klebsiella, and Staphylococ-
cus organisms; cytomegalovirus in-
clusion bodies were seen on
transbronchial biopsy.
A B

AJR:175, September 2000 815


tibacterial, antiviral, antipneumocystis, and
more recently, antifungal prophylaxis are all
used [16]. The universal use of trimethoprim-
sulphamethoxazole has virtually eliminated in-
fection caused by Pneumocystis and probably
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a number of other infections (e.g., Nocardia
organisms) [16].
Bacterial Pneumonia
Bacteria are the most common cause of infec-
tion in patients having undergone lung trans-
plantation [15]. In our study, bacteria alone
accounted for 16 (36%) of 45 pneumonias. Al-
though the incidence of bacterial pneumonia is
highest in the first month after transplantation,
bacterial pneumonia continues to be a major in-
fectious complication throughout the transplant
recipient’s life [3]. Bacterial pneumonia is usu-
ally caused by Staphylococcus aureus, Entero-
bacteriaceae, Pseudomonas aeruginosa, or other
gram-negative organisms [11, 17–19]. In our se-
ries, Pseudomonas organisms alone accounted
for seven (35%) of 20 bacterial pneumonias.
Pneumonia caused by a single bacterial species
is most common, but mixed organism and anaer-
obic infections may occur [20]. Fifteen (94%) of
the 16 bacterial pneumonias in our series were
caused by a single bacterial organism.
Isolation of Pseudomonas organisms from
the lung allograft occurs more frequently and
earlier after transplantation in recipients with
cystic fibrosis [21]. Although infections related
to Pseudomonas organisms also occur more
frequently in recipients with cystic fibrosis, no
increase in mortality was seen. In fact, most
major transplantation centers show no differ-
ence in survival rates for lung transplant recipi-
ents with cystic fibrosis and all other lung
transplant recipients [1]. Of our nine cases of
pseudomonas pneumonia, (including one case
of combined pseudomonas and staphylococcal
pneumonia and one case of combined
pseudomonas and aspergillus pneumonia), the
underlying disease before transplantation was
cystic fibrosis in three cases (33%).
The most common CT pattern in patients
with bacterial pneumonia was consolidation
and ground-glass opacification seen in eight
(50%) of 16 patients. However, nodules, con-
solidation, and ground-glass opacification
were all common manifestations of bacterial
pneumonia, occurring in 44%, 94%, and
81% of cases, respectively. Nodules were
various sizes, multiple, irregular, and in-
volved all lung zones. A tree-in-bud pattern
was seen in three (19%) of 16 bacterial pneu-
monias. Consolidation tended to occur in the
right middle and both lower lobes. Ground-
816
Collins et al.
glass opacification tended to involve all
lobes. Septal thickening and pleural effu-
sions were common and seen in 81% and
75% of bacterial pneumonias, respectively.
Viral Pneumonia
CMV is the most significant viral infection
and the most common opportunistic infection
occurring after lung transplantation [22].
CMV infection most commonly develops be-
tween 1 and 4 months after transplantation and
varies from asymptomatic infection to fulmi-
nant pneumonia [23]. CMV pneumonitis
develops in approximately one third of heart–
lung transplant recipients [24, 25]. Acute and
chronic allograft rejection is treated by in-
creasing the dose of immunosuppressive
drugs, which further increases susceptibility to
CMV infection. The viral infection creates a
state of immune activation, increasing the risk
of rejection. This cycle generates significant
diagnostic and treatment dilemmas [26]. Gan-
ciclovir prophylaxis reduces both the inci-
dence of CMV pneumonitis and the severity of
infection, while delaying the onset of chronic
rejection [26, 27].
CMV infection can take one of three
forms. Primary infection, the most serious,
occurs in seronegative recipients who receive
a graft from a seropositive donor. Seroposi-
tive recipients may develop reinfection if the
donor had been infected by a different CMV
strain, or they may reactivate their disease af-
ter immunosuppression. Other less common
atypical viral pathogens include herpes sim-
plex (less common now that acyclovir pro-
phylaxis is routine), varicella zoster (most
common manifestation is mucocutaneous in-
volvement), and Epstein-Barr virus (having
an important role in the development of lym-
phoproliferative disorders) [28].
Nodular opacities with coalescence are a
typical radiographic manifestation of CMV
infection [29]. CT findings include ground-
glass opacification, air-space consolidation,
airway dilatation, bronchial wall thickening,
and small pleural effusions [4, 30–32]. It has
been reported that in single-lung transplant
recipients, CMV pneumonitis often affects
only the transplanted lung [4]. In this series,
CMV infections occurred in 11 patients with
a single transplanted lung. The transplanted
lung alone was involved in six (55%) of 11,
both lungs in four (36%), and the native lung
only in one (9%).
No common CT pattern was found among
our patients with CMV pneumonia. Nodules,
consolidation, and ground-glass opacifica-
tion were all common CT findings, occurring
in 60%, 67%, and 67% of pneumonias, re-
spectively. Nodules tended to be multiple
and various in size and to involve all lung
zones. A tree-in-bud pattern was seen in one
(7%) of 15 cases of CMV pneumonia. Con-
solidation and ground-glass opacification in-
volved all lobes equally. Septal thickening
and pleural effusions were common, occur-
ring in 73% and 67% of cases, respectively.
Fungal Pneumonia
Fungal pneumonias are less common than
CMV pneumonia after transplantation but
are associated with a higher mortality [3, 33,
34]. Fungal pneumonias usually occur be-
tween 10 and 60 days after transplantation
[3, 35]. In the case of single-lung transplan-
tation, fungal pneumonia can involve the na-
tive lung; however, this situation is rare, with
the transplanted lung more commonly in-
volved [33, 36]. However, in our series of
three patients with a single transplanted lung
and fungal pneumonia, the native lung was
solely involved in one patient (33%), and
both lungs were involved in the other two pa-
tients (67%).
Lung transplant recipients have a much higher
incidence of aspergillosis compared with other
immunocompromised patients [37]. Infection
with Aspergillus organisms occurs most com-
monly 2–6 months after transplantation [38].
Locally invasive or disseminated aspergillus in-
fection accounts for 2–33% of post–lung trans-
plantation infections and 4–7% of all lung trans-
plantation deaths [6, 8, 37, 39–41]. In our series,
Aspergillus organisms were the sole infectious
agent in eight (18%) of 45 pneumonias.
The lung is the presumed portal of entry for
fungal spores, and direct invasion of the lung
or airway is present in most transplant recipi-
ents dying of invasive aspergillosis. This lung
involvement was confirmed in one study in
which invasive disease had a 100% mortality
rate, and 80% of the patients with invasive dis-
ease had fungal invasion of the transplanted
lung [42]. Although half of patients have As-
pergillus airways colonization at some point
after transplantation, invasive aspergillus dis-
ease is found in only 3% of patients [42]. Pa-
tients with Aspergillus fumigatus airways
colonization in the first 6 months after trans-
plantation are 11 times more likely to develop
invasive disease than those not colonized with
A. fumigatus during this period [42]. The total
number of Aspergillus organisms infections
does not differ between patients with and with-
out cystic fibrosis, and the isolation of As-
AJR:175, September 2000

pergillus organisms from the respiratory tract
occurs in 30–50% of patients in both groups
[43]. In our eight cases of aspergillus pneumo-
nia, three patients (38%) had cystic fibrosis.
The most common CT pattern among our
Downloaded from www.ajronline.org by 125.167.114.159 on 05/24/21 from IP address 125.167.114.159. Copyright ARRS. For personal use only; all rights reserved
patients with fungal pneumonia was a com-
bination of nodules, consolidation, and
ground-glass opacification, occurring in five
(63%) of eight patients. Nodules tended to be
multiple and various in size, have irregular
margins, and involve all lung zones fairly
equally. The tree-in-bud pattern was seen in
one patient (13%) with fungal pneumonia.
Although nodules were more frequently seen
in fungal compared with other types of pneu-
monia, this pattern was not statistically sig-
nificant. Consolidation tended to involve the
lower lobes and to be multifocal. Ground-
glass opacification tended to involve all lobes
fairly equally. Septal thickening and pleural
effusions were common, each occurring in
63% of patients with fungal pneumonia.
Mycobacterial Pneumonia
The incidence of pulmonary tuberculosis
after lung transplantation is estimated to be be-
tween 2% and 3.8% [44, 45]. The exact inci-
dence is unknown but presumably is low, with
only 12 instances of M. tuberculosis infection
after lung transplantation reported in the medi-
cal literature [45–50]. In our series of 45 pneu-
monias, we had only one case of tuberculosis.
Pulmonary tuberculosis after lung transplanta-
tion is probably transmitted via the donor al-
lograft [44]. The infection typically occurs
1.5–9 months after surgery (median time, 3.5
months) [44]. Our case occurred 4 months af-
ter surgery. Tuberculosis in the transplanted
lungs has no characteristic radiographic pat-
tern [46–48]. The findings include subtle bron-
chial narrowing, pleural effusions, multiple
bilateral small nodules, multiple bilateral up-
per and lower lobe cavitary lesions, pulmonary
consolidation, mediastinal lymph node en-
largement, and a solitary pulmonary nodule,
similar to the CT findings of multiple nodules,
consolidation, septal thickening, pleural effu-
sion, and lymph node enlargement that were
seen in our patient.
Because this study was retrospective, dif-
ferences were seen in CT protocols from the
two contributing medical centers. If some
patients were not scanned with high-resolu-
tion protocol, underestimation of the inci-
dence of ground-glass opacification could
have resulted. The frequency of lymph node
enlargement could have been underestimated
on CT performed without IV contrast mate-
AJR:175, September 2000
CT Findings After Lung Transplantation
rial or with high-resolution CT. The frequen-
cies of different infectious organisms that we
report cannot be assumed to be an accurate
reflection of the true overall frequency be-
cause only cases with abnormal findings on
CT and clear documentation of pneumonia
were included in the study. As with chest ra-
diography, it may be that patients can have
pneumonia and normal findings on CT. Al-
though we were careful to exclude any cases
of pneumonia with the possibility that the
patient had coexistent disease in the lungs,
coexisting conditions such as bronchiolitis
obliterans, which are patchy in distribution,
can be difficult to diagnose even with open-
lung biopsy. Some patients were treated pre-
sumptively for pneumonia but did not have
documentation of an infectious organism and
were excluded from the study. In some cases
of documented pneumonia, the patient did
not have CT within 7 days of diagnosis, and
these patients were also excluded.
In summary, the most common abnormal
pattern with bacterial pneumonia seen on CT
was consolidation and ground-glass opacifica-
tion; and with fungal pneumonia, the abnormal
pattern was a combination of nodules, consoli-
dation, and ground-glass opacification. No
predominant pattern was seen with viral pneu-
monia, although nodules, consolidation, and
ground-glass opacification were common
findings. When nodules, consolidation,
ground-glass opacification, septal thickening,
or pleural effusion is seen on CT in a patient
with a transplanted lung, they are not helpful in
making a specific infectious diagnosis. Lymph
node enlargement is uncommonly seen with all
types of pneumonia. Pneumonia in patients
with a single transplanted lung tended to in-
volve only the transplanted lung, except fungal
pneumonia, which involved either the native or
both lungs.
CT is useful in the lung transplant popula-
tion when chest radiographs show nonspecific
abnormal findings or when the radiographic
findings are normal with the patient showing
clinical findings of pulmonary disease. Our
study showed that CT does not distinguish be-
tween viral, bacterial, and fungal pneumonias.
However, it does show areas of lung that can
be targeted with bronchoscopic biopsy.
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