Community and Hospital Acquired Pneumonia

Kevin Delijani,*, Melissa C. Price,† and Brent P. Littlez

Community-acquired pneumonia is the most common cause of death among infectious dis-
eases, and responsible for millions of hospitalizations annually. Pneumonia may be classi-
fied based on how it is acquired, etiology, and clinical presentation. Chest radiographs are
the gold standard for initial imaging evaluation and chest computed tomography plays an
important role in diagnostic problem-solving and evaluation of complicated and treatment-
resistant pneumonia. Follow-up imaging with chest radiographs or computed tomography
post-illness resolution may be used to identify treatment-resistant inflammation or unidenti-
fied underlying malignancies.
Semin Roentgenology 57:3-17 © 2021 Elsevier Inc. All rights reserved.

Introduction potential complications, and treatments. Imaging modalities

such as CR and CT are required for initial diagnosis of pneu-

C ommunity-acquired pneumonia (CAP) is a leading

cause of morbidity and mortality and is the most com-
mon cause of death among infectious diseases.1 From 2001
to 2014, there were over 20 million hospitalizations for
pneumonia in the US.2 Although elderly and immunocom-
promised populations are most commonly affected, CAP is a
cause of significant morbidity and mortality regardless of age
or comorbidities; for example, in 2017 pneumonia was
responsible for 15% of all deaths in children under 5 years
old.3 Chest radiographs (CR) are the gold standard for initial
imaging evaluation of pneumonia,4 and chest computed
tomography (CT) plays an important ancillary role in diag-
nostic problem-solving and evaluation of complicated and
drug-resistant pneumonia.5 Appreciation of the role of imag-
ing in the diagnosis and treatment of CAP, awareness of typi-
cal imaging findings, and familiarity with common
complications of pneumonia are important for the radiologist
and multidisciplinary medical team to successfully diagnose
and treat CAP.
Common causes of CAP include bacterial, viral, and atypi-
cal organisms such as Legionella, Mycoplasma pneumoniae,
and Chlamydia pneumoniae. The various types of pneumonia
may have different clinical symptoms, imaging findings,
*Georgetown University School of Medicine, Washington DC.
y
Department of Radiology, Division of Thoracic Imaging and Intervention,
Massachusetts General Hospital, Boston, MA.
z
Department of Radiology, Division of Cardiothoracic Imaging, Mayo Clinic
Jacksonville, Jacksonville, FL.
Address reprint requests to Kevin Delijani, BS, Georgetown University
School of Medicine, 3954 Georgetown Ct NW. Washington DC, 20007.
(516) 423-6516. E-mail: kd767@georgetown.edu
monia and have proven useful in identifying additional com-
plications of the initial infection.6 Herein we will discuss the
common imaging findings of each subtype of pneumonia
and potential complications that may arise, with associated
clinical background.
Classification, organisms, and
clinical presentation
Pneumonia can be classified based on how it is acquired, eti-
ology, and clinical presentation. Traditional classifications of
pneumonia according to type of acquisition include (1) com-
munity acquired, (2) hospital acquired, and (3) healthcare
acquired pneumonia.
Community-acquired pneumonia (CAP) is defined as a
pulmonary infection (parenchyma or pleura) acquired out-
side the hospital.1 The most common etiology of CAP
remains Streptococcus pneumoniae. Others include bacteria
such as Mycoplasma pneumoniae, Haemophilus influenzae,
Legionella species, Staphylococcus aureus, and gram-negative
bacilli (including Pseudomonas and Klebsiella) (Table 1).
Although not as common, respiratory viruses such as influ-
enza, parainfluenza, human metapneumovirus and respira-
tory syncytial virus (RSV) may also cause CAP. Depending
on the specific etiology and comorbidities, patients can have
different clinical presentations.
Hospital-acquired pneumonia (HAP) refers to pneumonia
having been diagnosed greater than 24 hours after admission
to a hospital.1 Common causative agents of HAP include

https://doi.org/10.1053/j.ro.2021.10.006 3
0037-198X/© 2021 Elsevier Inc. All rights reserved.
4 K. Delijani et al.
Table 1 Selected Causes of Community Acquired in Adults75
Bacterial Viral/ Atypical
Streptococcus pneumoniae Influenza virus
Klebsiella pneumoniae Rhinovirus
Staphylococcus aureus RSV
Streptococcus pyogenes SARS-CoV-2
(Group A Strep)
Haemophilus influenzae Francisella tularensis
Pseudomonas Human metapneumovirus
Moraxella catarrhalis Chlamydia psittaci
Coxiella burnetii
Mycoplasma pneumoniae
Legionella
CMV
Adenovirus
gram-positive cocci such as Staphylococcus aureus and Strepto-
coccus pneumoniae, and gram-negative bacilli such as Pseudo-
monas aeruginosa, Klebsiella pneumoniae, Enterococcus coli,
and Enterobacter species.7
Healthcare associated pneumonia (HCAP) is pneumonia
that develops outside or inside the hospital in the presence of
risk factors for multi-drug resistant pathogens due to prior
contact with healthcare.8 Due to overlap in etiology and risk
factors, many of the guidelines that apply for HAP may also
be applied for HCAP.
Demographics and comorbidities
of patients with pneumonia
The severity of pneumonia and likelihood of mortality can be
influenced by age and comorbidities. Age older than 65 years
may be independently associated with pneumonia severity,9
and mortality increases with age, although this may in part
be due to a greater incidence of comorbidities in older
adults.10 Pneumonia in the elderly can also pose clinical diag-
nostic challenges, as classic symptoms such as fever, short-
ness of breath, and chest pain may be absent and
extrapulmonary symptoms such as mental status change or
gastrointestinal symptoms may be the dominant presenting
clinical findings.11 However, half of the non-immunocom-
promised adults hospitalized for severe pneumonia in the US
are ages 18-57 years, and half of the deaths from bacteremic
pneumococcal pneumonia occur in individuals ages 18-
64 years.12 Additionally, 15% of all deaths of children under
the age of 5 years worldwide are caused by pneumonia,
claiming the lives of 808,694 children in 2017, many of
whom were under the age of 2 years.13 Aside from increased
age, common risk factors of pneumonia include COPD and/
or chronic bronchitis, asthma, chronic heart disease, chronic
renal disease, diabetes, alcoholism and immunosuppression
(by therapy or pathology).14
Several assessment tools can be used to determine the risk
of severity in a patient with pneumonia. These include the
Pneumonia Severity Index (PSI), and the British Thoracic Society
CURB-65.15,16 The PSI, used to determine if a patient can be
treated as an outpatient, incorporated a patient’s age, vital
signs, CR, and comorbidities such as malignancies, liver dis-
ease, congestive heart failure, cerebrovascular disease, and
renal disease. In contrast, the British Thoracic Society CURB-65
uses clinical and a single laboratory measure. One point is
given for each of the following: confusion, urea > 7 mmol,
respiratory rate > 30/min, systolic blood pressure < 90 or dia-
stolic blood pressure < 60, and age > 65. Additional points
assigned to a patient reflect increased odds of mortality.
“Typical” and “Atypical”
Pneumonia
The classification “typical pneumonia” refers to pneumonias
with often acute onset of common symptoms like fever,
cough, and fatigue, usually with lobar or segmental opacities
on CR (Fig. 1). Pneumonias in this category are caused by
Streptococcus pneumoniae, Staphylococcus aureus, Group A
Streptococcus, Klebsiella pneumoniae, Haemophilus influenzae
(Fig. 2), Moraxella catarrhalis, anaerobes or gram-negative
organisms. Common signs and symptoms include fever,
cough, some variant of sputum production (mucopurulent is
indicative of a bacterial etiology), fatigue, headache myalgia
and arthralgias. Pleuritic chest pain may be seen in many
cases of pneumonia, although it is more common in lobar
pneumonia.17 In more severe cases of pneumonia a patient
may experience dyspnea, shortness of breath, confusion, sep-
sis, and multi-organ failure. Development of acute respiratory
distress syndrome (ARDS) can lead to severe morbidity with
high incidence of mortality.
“Atypical pneumonia” is a term used to describe a unique
clinical presentation of pneumonia categorized by the grad-
ual onset of respiratory and constitutional symptoms and an
unusual pattern on CR.17 In addition, patients with atypical
pneumonia may present with extrapulmonary symptoms,
such as hepatic involvement, gastrointestinal manifestations,
muscle involvement, or CNS, cardiac, or renal impairment,
that vary depending on the microorganism infecting the
patient.17 Causes of atypical pneumonia are often classified
as zoonotic (Francisella tularensis, Chlamydia psittaci, and Cox-
iella burnetii) or non-zoonotic (Mycoplasma, Legionella, and
viruses such as RSV, CMV, Influenza and Adenovirus).
Patients with atypical pneumonia may present with an indo-
lent course of illness. Some atypical pneumonias, such as
Legionella (Figs. 3 and 4), may show multifocal often nodular
or mass-like consolidation at imaging, while other etiologies
such as mycoplasma or viral pneumonias often show pre-
dominantly involvement of the interstitium and small air-
ways. At CR, interstitial involvement may cause patchy or
diffuse hazy opacities, sometimes with thickening of interlob-
ular septa and interlobar fissures. At CT, interstitial inflam-
mation can cause ground-glass opacities and septal
thickening, and tree-in-bud nodules can be seen, represent-
ing small airway involvement with bronchiolitis.18
Pneumonia 5

Figure 1 Community-acquired right middle lobe pneumonia in a 22-year-old female. (A, B) Frontal and lateral chest
radiographs show consolidation in the right middle lobe, obscuring the right heart border on the frontal radiograph
(arrows in A) and superimposed upon the anterior cardiac silhouette on the lateral radiograph (arrows in B). (C) Axial
chest CT image shows consolidation in the medial segment of the right middle lobe.

Role of imaging in diagnosis and
management
CR and CT imaging have unique roles in the diagnosis, treat-
ment, and follow-up of patients with pneumonia. When a
patient presents with clinical symptoms of pneumonia, CR are
seen as appropriate for initial diagnosis by the British Thoracic
Society, Canadian Thoracic Society, Japanese Respiratory Soci-
ety, and American College of Radiology (ACR) guidelines for
management of CAP.19-22 In the outpatient setting, the poster-
oanterior (PA) and lateral views are routinely obtained,
whereas the PA and lateral, or anteroposterior (AP) view may
be used in an inpatient setting for initial diagnosis. The ACR
guidelines reinforce the use of CR as the first imaging modality
in diagnostic workup of CAP.20 In contrast, CT is not initially
appropriate in the diagnosis of pneumonia. CT may be useful
when CR results are unclear, which often occurs in patients
with heart failure, emphysema, or pulmonary fibrosis. CTs
may also increase diagnostic sensitivity for small airway infec-
tion and may depict additional infections or complications
that may arise during the management of pneumonia.20,23-25
The ACR Appropriateness criteria recommend the use of CT
in immunocompromised patients when presenting with pneu-
monia complicated by suspected parapneumonic effusion or
abscess on initial CR.20 These complications include pleural
effusion, empyema, lung abscess, septicemia, and bacteremia.
Worldwide, pneumonia claimed the lives of 2.56 million
people in 2017.26 However, many deaths are preventable by
early identification and treatment.27 Initiating antibiotic treat-
ment soon after the onset of symptoms of pneumonia can
blunt the progression of the infection.28 In fact, one study
showed that administration of antibiotics within 4 hours of
arrival at a hospital is associated with a reduction in in-hospital
mortality, length of stay, and 30-day mortality.29
Common organisms and imaging
appearances
Appreciation of the often different clinical and imaging find-
ings of bacterial and viral pneumonias may be helpful in
6 K. Delijani et al.

Figure 2 Haemophilus influenzae pneumonia in a 49-year-old woman. (A) Frontal chest radiograph demonstrates innu-
merable small clustered nodular opacities bilaterally. Corresponding axial chest CT image (B) and coronal reformatted
CT image (C) show diffuse centrilobular “tree-in-bud” nodules within all lobes of the lungs.

guiding diagnosis and treatment. Certain imaging findings
and clinical scenarios can help suggest particular etiologies of
pneumonia.
Bacterial pneumonia
Bacterial pneumonia symptoms commonly include a cough
with purulent sputum, pleuritic chest pain that worsens with
inhalation or coughing, and a high fever ranging from 102°
to 105°.30 Bacterial pneumonia can be classified as lobar or
bronchopneumonia. Lobar pneumonia, most commonly
caused by Streptococcus pneumoniae and Klebsiella, is
characterized by exudative fluid filling the alveolar space
leading to consolidation often involving one or more seg-
ments of a lobe or an entire lobe (Figs. 5 and 6).31 In addition
to pneumonia, S. pneumoniae is a common cause of otitis
media, sinusitis, and meningitis. It is specifically more com-
mon in patients aged greater than 65 or less than 2, who
smoke, abuse alcohol and are immunodeficient.32 The classic
clinical description of pneumococcal pneumonia is the
abrupt onset of pleuritic chest pain and chills, followed by
fever, then cough with blood tinged or rusty sputum,
although presentations may vary.33 S. pneumoniae is respon-
sible for nearly half of cases of CAP, whereas Klebsiella

Figure 3 Legionella pneumonia in a 55-year-old woman. (A) Axial chest CT image at the level of the mid lungs shows a
mass in the right upper lobe (arrow) with a small amount of adjacent ground-glass opacity; a percutaneous CT-guided
biopsy revealed the diagnosis. (B) Axial CT image through the lower lungs shows multiple nodules bilaterally (arrows),
the largest of which is in the right lower lobe.
Pneumonia 7

Figure 4 Legionella pneumonia in a 70-year-old woman. (A) Frontal chest radiograph shows extensive mass-like con-
solidation bilaterally. (B) Axial chest CT image and (C) coronal reformatted CT image show somewhat rounded areas
of consolidation within the upper to mid lungs bilaterally (asterisks).

pneumonia is responsible for 3%-5%. Klebsiella pneumoniae
has rapidly gained antibiotic resistance, especially those
infections acquired in the hospital, due to alteration in the
organism’s core genome, and is increasingly difficult to treat.
The organism has a similar clinical presentation as S. pneumo-
nia, with the major difference in the production of “currant
jelly” sputum. The prognosis of Klebsiella is particularly poor
in diabetics, alcoholics, and patients with other comorbid-
ities. Expansile consolidation of a lobe or lung can be
observed, with displacement of interlobar fissures sometimes
observed at CR or CT. Potential complications include
abscesses, empyema, and bacteremia.34
Bronchopneumonia, characterized by acute inflammatory
infiltrates from bronchioles into adjacent alveoli, may be
caused by S. pneumoniae, Klebsiella, S. aureus, and H. influ-
enza. On imaging, a scattered, patchy consolidation centered
around bronchi in one or multiple lobes may be seen; find-
ings may be unifocal, multifocal, or asymmetric. S. aureus is
responsible for roughly 3% of cases of CAP,35 and is often
associated with influenza infection (Fig. 7).36 Additional risk
factors for infection include hemodialysis use, seizure disor-
der, diabetes, hemoptysis, alcoholism, cavitary infiltrates,
pleural effusions, and recent use of antibiotics.37 A significant
complication of S. aureus pneumonia is severe necrotizing
pneumonia, but sepsis, septic shock, bacteremia and respira-
tory failure are of concern as well.
Certain imaging appearances or clinical scenarios may sug-
gest particular types of bacterial infection.38 For example,

Figure 5 Streptococcal pneumonia in a 44-year-old man. Axial chest CT image presented at a lung window (A) shows
extensive lobar consolidation throughout the right lung (asterisk) and within the left lower lobe. Corresponding CT
image presented at a soft tissue window (B) shows low attenuation within a portion of the right middle lobe and lower
lobe (asterisk) concerning for development of a necrotizing component or nascent abscess.
8 K. Delijani et al.

Figure 6 Klebsiella pneumonia in a 63-year-old man. (A) Frontal chest radiograph shows extensive confluent opacity
throughout the right mid to lower lung (asterisks), with additional opacity in the basal left lower lobe (arrow); air bron-
chograms are seen within the right upper lobe and left lower lung. (B) Corresponding axial chest CT image shows con-
solidation within the right middle lobe and bilateral lower lobes (asterisks).

Klebsiella species may cause very confluent consolidation of
multiple segments or entire lobes with volume expansion; dis-
placement or a bulging contour of the fissures and displace-
ment of adjacent lung parenchyma away from the
consolidated lung may be seen.39 Aspiration-related pneumo-
nia may be seen in patients with poor clearance of secretions,
gastroesophageal reflux disease, or poor control of swallowing
mechanism; imaging findings can include posterior and lower
lung predominant consolidation, ground-glass opacities, and
clustered nodules with a tree-in-bud morphology, represent-
ing bronchiolar involvement (Fig. 8). Patients with poor denti-
tion can be especially prone to aspiration-related pneumonia
with gram-negative bacterial species, which can at times pro-
duce cavitary nodules or pulmonary abscess (Table 2).
Septic embolism is a form of pulmonary infection that is
often due to a bacterial etiology with a primary nidus of
infection that seeds the lung parenchyma through emboliza-
tion to the pulmonary arterial tree, although fungi and other

Figure 7 Methicillin-resistant Staphylococcus aureus pneumonia complicating influenza pneumonia in a 27-year-old

woman. (A) Frontal chest radiograph shows extensive consolidation bilaterally with nodular and mass-like compo-
nents (arrows). (B, C) Axial images from a chest CT obtained one month later show multiple cavities within previously
seen consolidation (white arrows); a small right pneumothorax is seen (black arrows), a result of rupture of one or
more cavities.
Pneumonia
Figure 8 Aspiration related pneumonia in a 73-year-old man with history of dysphagia due to neurologic disease. (A)
Frontal chest radiograph shows hazy bibasilar pulmonary airspace opacities (arrows). (B) Axial image from chest CT
performed the same day shows consolidation within the posterior lower lobes (arrows); pleural effusions are also pres-
ent bilaterally.
organisms are occasionally implicated (Fig. 9).40 Endocardi-
tis with valvular or intracameral vegetations is the usual
source. Major predisposing factors include intravenous drug
abuse, prior valvular surgeries, and sepsis. Other niduses for
infection that can lead to septic emboli include infected sep-
tic thrombophlebitis. At CR and CT, septic emboli usually
take the form of multiple nodules bilaterally with a periph-
eral and basilar distribution, reflecting the role of both vascu-
lar origin and gravitational blood flow gradient.18
Viral pneumonia
Viral pneumonias often have clinical presentations and imag-
ing findings that may help distinguish them from bacterial
pneumonias. Most viruses cause atypical pneumonia, charac-
terized by diffuse, patchy infiltrates with a predilection for
the interstitium and small airways. These include Adenovi-
rus, rhinovirus, Herpesviruses (CMV, HSV, VZV, and EBV),
RSV, human metapneumovirus (Fig. 10) and influenza.
Patients may present with subacute symptoms including a
low-grade fever, myalgias, and minimal sputum production.
Table 2 Selected Differential Diagnosis of CAP1
Pulmonary edema
Pulmonary hemorrhage
Atelectasis
Interstitial lung disease
Drug reaction
Pulmonary infarct
Aspiration pneumonitis
Radiation pneumonitis
Diffuse alveolar damage
Organizing or eosinophilic pneumonia
Lung cancer
“Alveolar” Sarcoidosis
Vasculitis
Lipoid pneumonia
Alveolar proteinosis
9
On imaging, viral pneumonia may present with bronchiolitis,
which presents as multifocal patchy hazy opacities on CR,
and often bilateral ground glass opacities and nodules on CT.
At CT, a “tree-in-bud” appearance of clustered nodules cen-
tered around the terminal bronchioles is typical, representing
inflamed bronchi with fluid and cells filling the bronchioles
and alveolar sacs and ducts.
Adenovirus is responsible for 5%-10% of respiratory tract
infections in adolescents and commonly infects military
recruits as well.41 Patients may present with laryngotracheo-
bronchitis, pharyngitis, bronchiolitis or bronchopneumonia,
although the course of disease is mild in most immunocom-
petent patients.42 Multifocal patchy or diffuse ground-glass
opacities and centrilobular ground-glass or tree-in-bud nod-
ules are common, often with patchy bronchocentric consoli-
dation.43 Rhinovirus has also been shown to be a common
cause of CAP in adults,44 commonly presenting as severe
cases with high rates of respiratory failure and mechanical
ventilation (Fig. 11).45 Although RSV may cause asthma,
bronchiolitis, and pneumonia in patients of all age groups,
infants and immunocompromised hosts are more likely to
have severe illnesses,46 and it is also the most common cause
of viral CAP in hospitalized children.47 On imaging, RSV dis-
plays an airway-centered distribution, with tree-in-bud opac-
ities and bronchial wall thickening.43 CMV, a virus in the
Herpesvirus family, often results in an asymptomatic or mild
course of illness, but may cause a life threatening pulmonary
infection in immunocompromised individuals, including
post-transplant patients or those on long term corticosteroid
therapy. Diffuse or patchy ground glass opacities may be
seen on CT, with poorly defined centrilobular nodules and
interlobular septal thickening.48 Influenza viruses, members
of the Orthomyxovirus family, cause a mild upper respiratory
tract infection in healthy hosts, whereas in the elderly,
infants, and patients with chronic diseases, they may cause
fulminant pneumonia or hemorrhagic bronchitis.43 CR in
patients with influenza pneumonia often shows reticulonod-
ular opacities bilaterally, and areas of consolidation may be
seen in the lower lobes.49
10 K. Delijani et al.

Figure 9 Septic emboli and chest wall infection in a 34-year-old man with history of intravenous drug abuse. (A) Axial
chest CT image shows multiple cavitary and noncavitary nodules bilaterally with a peripheral predominance (arrows).
(B) Axial image from the same CT on soft tissue window shows crescentic extra-pleural fluid centered upon the right
anterior chest wall and pleura (arrows), involving intercostal muscles and one of the sternocostal joints.

The emergence of Coronavirus Disease 2019 (COVID-19)
as a global public health emergency has somewhat altered
the work-up of patients presenting with pneumonia.
Although bacterial coverage of a patient presenting with CAP
remains recommended by the co-chairs of the American Tho-
racic Society and Infectious Diseases Society of America
Guideline for Treatment of Adults with CAP as of May
2020,50 there has been a decrease in the proportion of
patients presenting with bacterial CAP as COVID-19 became
increasingly common.51 Early in the pandemic, a shortage of
PCR testing led to the use of chest CT in the initial diagnosis
of COVID-19 pneumonia, and subsequent studies found this
imaging technique to have a high sensitivity in this setting.52
Although the death rate is highly variable depending on the
age and comorbid conditions of the patient, COVID-19
pneumonia can be severe in up to 15% of cases, requiring
treatment in a hospital setting. The mainstays of treatment
include oxygenation, anticoagulation, remdesivir,

Figure 10 Metapneumovirus pneumonia in a 34-year-old man. (A, B) Axial chest CT images show extensive, confluent
clustered centrilobular and acinar nodules bilaterally (arrows); small pleural effusions are also present. (C) Chest CT
performed 2 weeks later shows extensive consolidation and ground-glass opacity bilaterally with a posterior predomi-
nance, corresponding clinically to acute respiratory distress syndrome.
Pneumonia 11

Figure 11 Human rhinovirus pneumonia in a 32-year-old female. (A) Axial and (B) coronal reformatted chest CT images
show bilateral ground-glass opacities with a central predominance (black arrows in A); a few scattered clusters of small
nodules are also seen (white arrow in A). Pleural effusions and septal thickening are absent, suggesting against pulmo-
nary edema as a diagnosis.

tocilizumab, convalescent plasma, and corticosteroids.
COVID-19 cases, hospitalizations, and deaths have signifi-
cantly decreased in countries and regions in which large-
scale vaccination has occurred. However, the disease
remains a significant cause of morbidity and mortality in
many countries around the world, highlighting the impor-
tance of prompt diagnosis and therapy. Findings of
COVID-19 at CR include often bilateral peripheral and
lower zone predominant opacities, usually without pleural
effusions or lobar consolidation. On CT, COVID-19 usually
presents as bilateral peripheral predominant ground glass
opacities; cavitation, lobar consolidation, adenopathy, tree-
in-bud nodules, and pleural effusions are uncommon
(Fig. 12).53 Although nucleic acid amplification testing
such as RT-PCR from nasopharyngeal swabs remains the
gold standard for COVID-19 diagnosis, imaging can be
used for triage in cases in which testing is unavailable or
delayed, and may help prompt further testing in cases of
initially false negative PCR.54 Although sensitivity of CT in
COVID-19 respiratory infection is high, false negatives can
occur, especially early in the disease, findings typical for
COVID-19 can also be seen in other viral pneumonias,
including influenza, and also in non-infectious organizing
pneumonia due to many causes.55,56

Figure 12 Two patients with COVID-19 pneumonia. (A) Frontal chest radiograph of a 64-year-old woman shows pre-
dominantly peripheral and basilar hazy pulmonary opacities bilaterally (arrows). (B, C) axial chest CT images of a 40-
year-old man show bilateral peripheral ground-glass opacities and bandlike consolidation in the mid lungs (B, arrows),
with more diffuse ground-glass opacities within the basilar lower lobes (C, arrows).
12 K. Delijani et al.

Differential diagnosis of
pneumonia on imaging
Imaging can often confirm the diagnosis of pneumonia in a
patient presenting with common upper respiratory symp-
toms, but many other conditions can present with imaging
findings in common with infectious pneumonia.
Consolidation, ground-glass opacities and nodules can
occur in other acute respiratory conditions such as pulmonary
edema, pulmonary hemorrhage, aspiration pneumonitis, radi-
ation pneumonitis, diffuse alveolar damage, or other forms of
acute lung injury. In the subacute to chronic setting, a number
of inflammatory pneumonias such as organizing or eosino-
philic pneumonia or vasculitides such as granulomatosis with
polyangiitis (GPA) has also been found to present with find-
ings mimicking infectious pneumonia.57 Importantly, chronic
consolidation and ground glass opacities that persist or worsen
over time can be seen in certain primary lung malignancies
such as adenocarcinoma or pulmonary muscosa-associated
lymphoid tissue (MALT) lymphoma (Fig. 13), which can
evade prompt diagnosis by mimicking pneumonia, providing
an important reason to obtain follow-up of imaging findings
suspected to be pneumonia. Post-obstructive pneumonia can
be caused by an obstructing airway lesion in the setting of
lung malignancy, often presenting as recurrent pneumonia.
Clinical findings of infection may help distinguish pneu-
monia from other causes of parenchymal disease at imaging
but overlap between symptoms of pneumonia and other con-
ditions can complicate diagnosis, and imaging can often help
narrow the possibilities. The time course of imaging findings
often provides helpful clues: conditions such as pulmonary
edema or aspiration may cause opacities that develop rapidly
and resolve quickly, in contrast to infectious pneumonia, in
which opacities often take hours to days to develop and days
to weeks to resolve completely.58,59 In contrast, inflamma-
tory conditions such as organizing pneumonia or GPA often
present with subacute worsening of opacities, and malignan-
cies such as adenocarcinoma or lymphoma usually have
chronic time courses of months to years. Ancillary findings
may also help distinguish other causes of parenchymal opaci-
ties from pneumonia. For example, septal thickening, pleural
effusions, and cardiomegaly can be ancillary findings of pul-
monary edema in heart failure, and a large amount of fluid or
debris in airways may be seen in aspiration.
Imaging of Complications of CAP
Although early diagnosis and treatment of CAP may improve
outcomes, many complications may arise. Identification of
common sequelae relies on both CR and CT, and thus there
may be benefit to standardized follow-up imaging in the
management of CAP. Complications are discussed in more
detail in other chapters of this volume.
Empyema
An empyema is a loculated collection of infected fluid in the
pleural cavity. An empyema is caused by an inflammatory

Figure 13 Mucosa-associated lymphoid tissue (MALT) lymphoma mimicking pneumonia in a 69-year-old man. (A)
Frontal and (B) lateral chest radiographs show focal consolidation in the superior segment of the right lower lobe
(white arrows) and right middle lobe (black arrows). (C) Radiograph performed 5 weeks later shows no change in con-
solidation. (D, E) Corresponding chest CT images show mass-like consolidation in the right lower lobe (D, white
arrow) and right middle lobe (E, black arrow), and biopsies revealed MALT lymphoma.
Pneumonia 13

Figure 14 Necrotizing pneumonia with bronchopleural fistula and empyema in a 43-year-old man. (A, B) Frontal and
lateral chest radiograph images show consolidation in the right middle and right lower lobes and loculated right pleural
fluid (arrows). (C, D) Axial and sagittal contrast-enhanced CT images show heterogeneously enhancing consolidation
in the right middle and right lower lobes with loculated right pleural fluid and thickening and enhancement of the vis-
ceral and parietal pleura (arrows).

condition (often pneumonia) in the lungs that leads to pleu-
ral extension of exudative fluid. At CR, a loculated pleural
fluid collection can be suggestive but is a nonspecific finding.
At CT, a loculated pleural effusion with thickening and
enhancement of the pleura - the “split pleura sign” - is a sug-
gestive finding, although malignant and inflammatory pleural
effusions can also have this appearance (Fig. 14). An empy-
ema may also contain gas, either from gas-forming organisms
or from a bronchopleural fistula in the setting of necrotizing
pneumonia. Treatment of empyema may include a course of
antibiotics, drainage of the fluid (often by tube thoracos-
tomy), or surgical intervention (video assisted
thoracotomy).60
Pneumothorax
Air may enter the pleural cavity in the setting of pneumonia,
leading to a pneumothorax. This may occur spontaneously
(primary or secondary) or due to trauma: including intense
coughing, cavity formation and rupture, or barotrauma if
intubation was required. The increased intrathoracic pressure
may cause a lung to partially or completely collapse.61 On
CR, a pleural line with associated peripheral lucency can be
seen, but in equivocal or complex cases, CT may be used and
offers more accurate estimation of the size of pneumothorax
and underlying pathologies.62
Bronchopleural fistula
Pneumonia can also cause a bronchopleural fistula due to
necrosis of lung parenchyma, often in conjunction with an
empyema.63 The clinical presentation may range from acute
symptoms of pneumothorax to subacute symptoms of empy-
ema.63 Bronchopleural fistulas may be suspected when a
pneumothorax or hydropneumothorax develops or enlarges
in the setting of infection, or when there are other signs of air
14
leak despite chest tube placement. An air-filled tract form the
lung to the adjacent visceral pleura is diagnostic at CT; how-
ever, the tract may be small or obscured by fluid, secretions,
or edema, and lack of visualization does not exclude a bron-
chopleural fistula.48
Necrotizing pneumonia and pulmonary
abscess
Necrotizing pneumonia, or sometimes referred to as cavitary
pneumonia, is a serious complication, often of bacterial pneu-
monia, characterized by the necrosis of lung tissue following
consolidation. This complication is more common in patients
with concomitant conditions such as diabetes, alcohol abuse,
and corticosteroid therapy.64 Common symptoms are gener-
ally nonspecific, and include shortness of breath, cough, chest
pain, and fever, but may include purulent sputum and confu-
sion.65 Areas of necrosis may coalesce, eventually forming a
lung abscess or pulmonary gangrene if an entire lobe is
involved.66 On CT, this would present as pneumonic consoli-
dation and distinct areas of low attenuation with decreased
parenchymal enhancement (Figs. 15 and 16).67
Multi-organism and secondary infections
Although most cases of CAP are caused by a single organism,
multi-organism infections are not uncommon.68 A recent
study found that 13.6% of 235 patients identified with CAP
and 22% of the patients with severe CAP, with overall worse
outcomes, were coinfected with bacteria and virus.69 This
study revealed that co-infection in CAP is common and
increases the associated morbidity in adults.
Viral infections of the lung parenchyma may be further
complicated with superimposed bacterial or an additional
infection.70 Immunosuppression is a risk factor for secondary
pneumonia, and common etiologies may change as through
Figure 15 Pulmonary abscess due to pneumonia in an 82-year-old
man. Axial chest CT image shows consolidation in the left lower
lobe, representing lobar pneumonia (arrows); a round area of lower
attenuation with peripheral enhancement within the consolidation
(asterisk) represents an abscess.
K. Delijani et al.
pandemics, such as in the COVID-19.70 Superinfection may
be seen on imaging as lobar or segmental consolidation
appearing after the diagnosis of a viral infection.
Acute respiratory distress syndrome
Pneumonia may lead to acute respiratory distress syndrome
(ARDS) as fluid may leak into damaged alveoli, leading to
pulmonary edema and decreased arterial oxygenation.
Although the presentation of ARDS may vary depending on
the phase of the disease (early or late),71 classic findings at
CR include bilateral opacities with a lower lung and periph-
eral distribution; CT classically shows a mixture of lower
lung predominant posterior consolidation bilaterally and dif-
fuse ground-glass opacities within the remainder of the
lungs.72
Role of Additional Imaging
The time course of illness in pneumonia is influenced by a
number of factors including a patient’s age, comorbid con-
ditions, and etiology. In previously healthy adults, pneumo-
nia often takes 2-3 weeks to resolve, yet most symptoms
may begin to resolve in 3-5 days with antibiotic treatment.
In elderly patients with comorbid conditions, the time
course to resolution can extend to longer than one month
with an extension and greater burden of symptoms.73 Due
to the variability of time to resolution, certain guidelines
and experts recommend follow-up imaging 6-8 weeks after
resolution of disease, while other societies do not make spe-
cific recommendations.74 Follow-up imaging is recom-
mended for multiple reasons. Identifying ongoing
inflammation and pneumonia resistant to treatment may
require an adjustment in therapy. Additionally, the patient
may have underlying pulmonary pathologies such as malig-
nancy or other inflammatory conditions that may have been
misinterpreted on CR or obscured by ongoing inflammation
during active infections. In a study of outcomes of follow-
up radiographs recommended by radiologists in cases of
suspected pneumonia by Little et al., 9 of 618 (1.5%) cases
represented malignancy, and an additional 23 cases (3.7%)
represented an important alternative disease other than
pneumonia.74 Upon follow-up, CR is generally seen as a
standard option, but CT may also be used in cases of subtle
findings or equivocal imaging.
Conclusion
CAP is a major cause of hospitalization, morbidity, and mor-
tality among infectious diseases in the US and worldwide.
Typical or atypical pneumonia may present with varying
clinical presentations and findings on imaging. There are
many etiologies that have unique predisposing factors, symp-
toms, and findings on CR, the gold standard in diagnosis of
CAP. CT is often used when the results of CR are unclear, or
in the diagnosis of complications. Follow-up imaging with
Pneumonia 15

Figure 16 Fusibacterium abscess in an 88-year-old man with myasthenia gravis. (A) Axial CT image shows a spiculated
mass in the superior segment of the right lower lobe (arrow). The CT was obtained to exclude thymoma given history
of myasthenia gravis. (B) PET-CT image demonstrates FDG uptake within the mass, which was considered suspicious
for primary lung cancer. (C) Prone CT image obtained during percutaneous biopsy shows the biopsy needle positioned
within the mass. Microbiology specimen from the biopsy grew Fusobacterium nucleatum and pathology demonstrated
fibrosis, reactive changes and acute on chronic inflammation, consistent with an abscess. (D) Axial chest CT image 5
weeks after the initial CT after completion of antibiotic therapy shows contraction of the abscess with cavitation
(arrow), consistent with a healing post-infectious pneumatocele.

CR or CT post resolution of illness may be used to identify
treatment-resistant inflammation or previously unidentified
complications such as malignancies.
Financial Disclosures
This research did not receive any specific grant from fund-
ing agencies in the public, commercial, or not-for-profit
sectors.
Declaration of Competing
Interest
None of the authors have identified a conflict of interest.
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