Cavitary Lung Diseases: A Clinical-Radiologic Algorithmic Approach

[ Special Features ]
Cavitary Lung Diseases

A Clinical-Radiologic Algorithmic Approach
Khalid Gafoor, DO; Shalin Patel, MD; Francis Girvin, MD; Nishant Gupta, MD, FCCP; David Naidich, MD, FCCP;
Stephen Machnicki, MD; Kevin K. Brown, MD, FCCP; Atul Mehta, MD, FCCP; Bryan Husta, MD, FCCP;
Jay H. Ryu, MD, FCCP; George A. Sarosi, MD; Tomás Franquet, MD; Johny Verschakelen, MD; Takeshi Johkoh, MD, PhD;
William Travis, MD; and Suhail Raoof, MD, Master FCCP
Cavities occasionally are encountered on thoracic images. Their differential diagnosis is large
and includes, among others, various infections, autoimmune conditions, and primary and
metastatic malignancies. We offer an algorithmic approach to their evaluation by initially
excluding mimics of cavities and then broadly classifying them according to the duration of
clinical symptoms and radiographic abnormalities. An acute or subacute process (< 12 weeks)
suggests common bacterial and uncommon nocardial and fungal causes of pulmonary
abscesses, necrotizing pneumonias, and septic emboli. A chronic process ($ 12 weeks)
suggests mycobacterial, fungal, viral, or parasitic infections; malignancy (primary lung cancer
or metastases); or autoimmune disorders (rheumatoid arthritis and granulomatosis with
polyangiitis). Although a number of radiographic features can suggest a diagnosis, their lack of
specificity requires that imaging findings be combined with the clinical context to make a
confident diagnosis. CHEST 2018; 153(6):1443-1465
KEY WORDS: cavitary; cavitating infections; cavitation; cavity; focal lucencies; necrotic lesions
To date, there are few specific guidelines A cavity, as defined by the Fleischner Society,
published on the optimal approach to is a gas-filled space, seen as a lucency or
cavitary lung disease.1,2 The intention of this low-attenuation area, within a nodule, mass,
review is to highlight the specific clinical, or area of parenchymal consolidation.3 It has
laboratory, and radiographic features that a clearly defined wall > 4 mm thick.2
can help guide clinicians in their approach. Although any strict definition would be
For purposes of this report, radiographic arbitrary, we suggest that acute and subacute
findings refer to abnormal chest imaging cavities are those < 12 weeks old (according
features seen on CT scans of the chest. to prior imaging or duration of symptoms),
ABBREVIATIONS: CNA = chronic necrotizing aspergillosis; GPA = VA Health Care System, Minneapolis, MN; Department of Radiology
granulomatosis with polyangiitis; ILD = interstitial lung disease; IPA = (Dr Franquet), Hospital de la Santa Creu i Sant Pau, Spain; Radiology
invasive pulmonary aspergillosis; MAC = Mycobacterium avium (Dr Verschakelen), University Hospital Gasthuisberg, Belgium; Radi-
complex; NTM = nontuberculous mycobacteria; RA = rheumatoid ology (Dr Johkoh), Kinki Central Hospital of Mutual Aid Association
arthritis of Public School Teachers, Japan; and Department of Pathology (Dr
AFFILIATIONS: From the Pulmonary Division (Drs Gafoor, Patel, Travis), Memorial Sloan Kettering Cancer Center, New York, NY.
Husta, and Raoof) and Department of Radiology (Dr Machnicki), CORRESPONDENCE TO: Suhail Raoof, MD, Pulmonary Division,
Lenox Hill Hospital Northwell Health, New York, NY; Department of Lenox Hill Hospital, 130 E 77th St, New York, NY 10075; e-mail:
Radiology (Drs Girvin and Naidich), NYU—Langone Medical Center, suhailraoof@gmail.com
New York, NY; Pulmonary, Critical Care and Sleep Medicine (Dr Copyright Ó 2018 American College of Chest Physicians. Published by
Gupta), University of Cincinnati, Cincinnati, OH; Medicine (Dr Elsevier Inc. All rights reserved.
Brown), National Jewish Health, Denver, CO; Pulmonary (Dr Mehta), DOI: https://doi.org/10.1016/j.chest.2018.02.026
Cleveland Clinic, Cleveland, OH; Pulmonary/CCM (Dr Ryu), Mayo
Clinic, Rochester, MN; Infectious Diseases (Dr Sarosi), Minneapolis
chestjournal.org 1443
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and chronic cavities are $ 12 weeks old. We derived the helpful in gauging the tempo of the disease process—a
definition of “chronic” from the US National Center for rapidly evolving cavity (< 12 weeks) strongly suggests
Health Statistics, which defines a chronic condition as an acute infectious cause. In contrast, cavities with a
one lasting 12 weeks (3 months) or longer.4 Before we more chronic or indolent evolution ($ 12 weeks)
delve deeper into a discussion about cavitary lung suggest chronic infections, autoimmune conditions, or
disease, it is important to discuss conditions that mimic malignancy. However, there may be significant overlap
cavities. These include cysts, emphysema, infected in temporal evolution of cavitary disease processes,
bullae, and cystic bronchiectasis. depending in part on the patient’s immune status and
comorbidities.
It is also helpful to recognize the chest imaging findings
that can guide clinicians to a particular diagnosis. For Step 1: Are We Dealing With True Cavities?
example, multiple peripheral nodules in varying stages
True cavities must be differentiated from their mimics,
of cavitation (Fig 1) indicate septic emboli, pulmonary
such as cystic disease, emphysema, infected bullae, and
Langerhans cell histiocytosis, or possible infarction.
cystic bronchiectasis. The definitions and radiographic
Bronchiectasis and accompanying peripheral small
appearances of these mimics that distinguish them from
airways disease (Fig 2) typically indicate widespread
cavities are summarized in Table 1.5-8
chronic infection. Halo (Fig 3) and reversed halo (Fig 4)
signs often are seen in association with various Step 2: Assess Disease Duration
rheumatologic diseases, infections (including fungal), Use the patient’s history and previous chest images to
septic emboli, pulmonary infarcts, and malignancies, estimate disease duration. If the estimated disease
especially metastatic disease with hemorrhage such as duration suggests an acute or subacute process
choriocarcinoma. An irregular internal wall (Fig 5) is (< 12 weeks), see step 3. If it is more than 12 weeks,
seen more frequently in malignant cavitary lesions. see step 4.
Linear outer border, associated bronchial wall
thickening, satellite nodules, consolidation, and ground- Step 3: Acute and Subacute Cavities (< 12 Weeks
glass opacities are associated more commonly with in Duration)
benign cavitary lesions. Although the differential diagnosis of an acute or
subacute cavity is wide, the first step is to rule out recent
Algorithmic Approach infection. Clinical features suggesting infection include
fever, chills, and cough.9 Laboratory values that suggest
In our algorithmic approach (Fig 6), we begin with
an acute bacterial infection include sputum cultures
ensuring that the lesions visible on CT scans are cavitary
demonstrating respiratory pathogens, elevated white
lesions. It is important to distinguish these lesions from
blood cell count with shift to the left, and elevated
mimics of cavitary lesions. We emphasize accompanying
procalcitonin C levels. For fungal infections, blood
radiographic features that may point toward specific
cultures, b-D-glucan level, galactomannan level, as well
causes. In addition, we discuss how acuity or chronicity
as measurements of specific fungal antigens in the blood
of cavitation, clinical features, and other laboratory
and urine, may be important. Cavitary Mycobacterium
indexes influence the likelihood of diagnosis.
tuberculosis can manifest acutely; however, it is more
Comparison with prior imaging, when available, is
likely to have a chronic manifestation and is discussed
later. Common infectious causes, including bacterial
lung abscesses, necrotizing pneumonias, septic emboli,
and acute fungal infections, are described here and
summarized in Table 2.
Bacterial Pathogens: Lung abscesses are pus-
containing necrotic lesions of the lung parenchyma
that show an air-fluid level at chest imaging. Microbial
cultures performed from lung abscesses usually
demonstrate multiple pathogens.10-12 These include
Figure 1 – Axial CT scan obtained in a 55-year-old man with a skin microaerophilic streptococci and viridans streptococci,
abscess leading to methicillin-resistant Staphylococcus aureus bacter-
emia and septic emboli. There are multiple nodules in varying stages of which were considered the most common.13 However,
cavitation. studies from Japan and Taiwan have implicated both
1444 Special Features [ 153#6 CHEST JUNE 2018 ]

Figure 2 – A-B, Axial CT scans (A, B) obtained in a 52-year-old man with culture-positive Mycobacterial tuberculosis. Thick-walled cavity and
multiple tree-in-bud opacities appear posteriorly in the apical segment of the right upper lobe.
Streptococcus species and Klebsiella pneumoniae as the a left shift and elevated values of C-reactive protein
most frequent causes of cavitary disease, suggesting level, erythrocyte sedimentation rate, and procalcitonin
that the bacteriologic aspects of cavity formation may C level.10 Radiographically, a lung abscess appears as a
be changing.13,14 Less frequently isolated organisms cavity with thick walls, irregular luminal margins and
include Staphylococcus aureus, Pseudomonas outer borders and typically demonstrates an air-fluid
aeruginosa, Haemophilus influenzae (type B), level (Fig 7). Lung abscesses are usually unilateral and
Acinetobacter species, Escherichia coli, and Legionella solitary and predominantly occur in the posterior
species. Contributing clinical factors are alcoholism, segments of the upper lobes and superior segments of
diabetes mellitus, generalized convulsive disorders, the lower lobes. This distribution is particularly
drug abuse, older age, and dental infections.15 Patients suggestive of prior aspiration—a diagnosis suggested
often have high fevers, night sweats, cough with foul- by the finding of centrilobular, tree-in-bud opacities in
smelling sputum, hemoptysis, fatigue, and weight loss. a similar anatomic distribution on prior chest imaging
These symptoms can go on for weeks—longer than studies.16,17 Pleural effusion and empyema have been
what is typical for community-acquired pneumonia. associated with lung abscesses 25% and 8% of the time,
Laboratory test abnormalities include leukocytosis with respectively.18
Necrotizing pneumonia is a rare but severe complication
of a bacterial infection.19,20 Acute necrotizing
pneumonia often is caused by S aureus, Streptococcus
pneumoniae, K pneumoniae, H influenzae, and P
aeruginosa.21 Of special interest is community-acquired
methicillin-resistant S aureus containing the gene for
Panton-Valentine leukocidin, a toxin known to cause
necrotizing pneumonia with rapid development of
respiratory failure and shock.19 Clinical factors
contributing to the development of acute necrotizing
pneumonia are similar to those in lung abscesses and
include diabetes mellitus, alcohol abuse, and
corticosteroid therapy. Patients with acute necrotizing
pneumonia typically appear severely ill with cough,
Figure 3 – Axial high-resolution CT scan demonstrates a solid central fever, hypoxia, tachycardia, tachypnea and rapidly
nodule surrounded by ground-glass opacity—the halo sign. progress to respiratory failure and septic shock.
Figure 4 – A-B, Axial CT scan (A) obtained in a 47-year-old woman with acute myelogenous leukemia and pulmonary mucormycosis. There is central
ground-glass attenuation with a rim of more dense consolidation— the reversed halo sign. There is small adjacent ground-glass opacity. Axial CT scan
(B) obtained in a 57-year-old man with aortic valve endocarditis and septic emboli. The left lower lobe has subpleural air-space opacity, comprising
central ground-glass attenuation and a rim of more dense peripheral consolidation, consistent with the reversed halo sign. Also, there are several
nodules at the right base, including a cavitary nodule medially.
Laboratory test abnormalities are similar to those found compared with abscesses.19,24 Surgical intervention has
in lung abscesses, as previously mentioned.15,16 been recommended early on if lung necrosis and
Characteristic radiographic findings include areas of gangrene have set in because antibiotic penetration to
consolidation containing multiple foci of poorly defined the affected areas is compromised by diminished or
low attenuation areas suggestive of necrosis. These absent blood supply.25,26 Pleural effusions are
changes are identified best on chest CT scans following associated with necrotizing pneumonia approximately
IV administration of contrast material. These areas 23% of the time,24 some of which can be empyema.
subsequently may coalesce to form larger cavities and, if The incidence of this complication is difficult to assess
this process continues, can lead to frank lobar gangrene because conclusions are drawn from small studies and
(Fig 8). case reports. One study reports empyema in 6 of
100,000.27
Features on the CT scan that point toward lung
gangrene include obscuration of the pulmonary arterial Septic pulmonary emboli result from hematogenous
supply to the involved segment or lobe and paucity of seeding from an infected extrapulmonary site.28 Risk
contrast material uptake in the lung parenchyma with factors include IV drug use and infected invasive devices
central necrosis affecting > 50% of the involved lobe such as central venous catheters and pacemakers and
(Fig 9).22,23 Necrotizing pneumonia tends to occur in other such as prosthetic valves. Septic thrombophlebitis,
regions of the lung that are less gravity dependent pelvic thrombophlebitis, and Lemierre syndrome also
Figure 5 – A-B, Coronal (A) and axial (B) CT scan images obtained in a 66-year-old man demonstrating a thick-walled cavitary mass with an irregular
internal wall in the superior segment of the left lower lobe. Pathologic test results helped confirm primary squamous cell carcinoma of the lung.

Focal hyperluciencies-Suspect pulmonary cavitary disease
Confirm cavities
Step 1
(Exclude mimics)
Mimics
Cysts
Review old imaging studies (if available) +
Emphysema Step 2
Obtain history to determine duration of disease
Infected Bullae
Cystic Bullae
Acute/subacute Chronic
Step 3 Step 4
(<12 weeks) (≥12 weeks)
Step 5 Step 6 Step 7
Acute infections Chronic Infections Malignancy Autoimmunity
Clinical History & Investigations: Clinical History & Investigations:

Clinical History & Clinical History & Investigations:
Fever, chills, productive cough, Older, weight loss, chronic
Investigations: History of connective tissue
aspiration risk, elevated WBC, cough, hemoptysis, fatigue,
Fevers, weight loss, chronic disease, arthralgia, myalgias,
elevated Pro-calcitonin smoking history,
cough, hemoptysis, fatigue rash, fever, positive serology.
(bacterial infections) history of malignancy
CT features CT features CT features CT features
Lung abscess TB
Primary lung
Necrotizing pneumonia NTB
cancer RA
Septic emboli Fungal
Metastatic lung GPA
Fungal infection Parasitic
disease
Nocardia Viral
See Table 2 See Table 3 See Table 4 See Table 5
Figure 6 – Algorithmic approach to cavitary lung disease. GPA ¼ granulomatosis with polyangiitis; NTM ¼ nontuberculous mycobacteria; RA ¼
rheumatoid arthritis.
may be implicated.1,29 Fever, dyspnea, chest pain, cough, respiratory tract, skin, and GI tract are the primary
fatigue, and hemoptysis are frequently present. portals of infection. Patients with defects in cell-
Progression to respiratory failure, septic shock, mediated immunity are predisposed to infection,
empyema, or renal failure can occur. Positive blood including patients who have undergone solid organ or
cultures are common, and the most commonly isolated stem cell transplant who are receiving
organisms are staphylococcal species, Fusobacterium immunosuppressive therapy and those with AIDS,
necrophorum, K pneumoniae, and Streptococcus lymphoma, and leukemia. Low-grade fevers, weight loss,
viridans.29,30 Radiographically, septic emboli appear as cough, fatigue, and chest pain are often present, and
well-defined, peripheral or subpleural nodules of various acute respiratory failure can occur.10 The CNS is the
size (0.5-3.5 cm) with evidence of cavitation in up to most common extrapulmonary site of infection with
85% of patients. A characteristic feature is the finding of Nocardia. Patients may have one or more brain
nodules simultaneously appearing in various stages of abscesses and can have symptoms of headache, nausea,
cavitation because of repeated seeding of the lungs, most vomiting, seizures, or altered mental status.31
often from endocarditis. As further evidence of a Radiographically, pulmonary nodules and consolidation
hematologic origin, nodules may be associated with are common, and cavitation can occur in both (Fig 11).
feeding vessels, variously reported in 67% to 100% of Pulmonary nodules range in size from 0.6 to 2.9 cm.
cases (Fig 10).24,29,31-33 Seventy-five percent of cases may have a crazy-paving
Pulmonary nocardiosis most commonly is caused by appearance around nodules, cavities, masses, or
Nocardia asteroides, which is found primarily in soil; the consolidation.32 Crazy-paving is defined as an area of
TABLE 1 ] Cavity Mimics
Cavity Mimic Definition or Radiographic Appearance CT Scan
Cyst Round parenchymal lucency with a
well-defined thin wall (< 2 mm
thick)5
Emphysema Focal areas or regions of low

attenuation, usually without
visible walls6
Infected bullae Radiographic evidence of previous

bullous disease and the
development of an air-fluid level7
Cystic bronchiectasis Lack of bronchial tapering and an

increased bronchoarterial ratio8

TABLE 2 ] Acute and Subacute Cavities
Cavity Patient Background Radiographic Findings Laboratory Findings
Lung abscess Alcoholism, diabetes mellitus, Typically unilateral and Positive sputum cultures
convulsive disorders, drug solitary cavities with thick, Leukocytosis with left shift,
abuse, elderly, and dental irregular walls, often with elevated procalcitonin C
infections an air-fluid level level
High fevers, night sweats, Predominantly in the
cough with foul-smelling posterior segments of the
sputum, fatigue, and weight upper lobes and superior
loss segments of the lower
lobes
Necrotizing Diabetes mellitus, alcohol Usually unilateral and Positive sputum cultures
pneumonia abuse, and corticosteroid solitary pulmonary Leukocytosis, elevated
therapy consolidation with multiple procalcitonin C level,
Usually severely ill, may have foci of poorly defined low- elevated ESR and CRP
respiratory failure and shock density areas suggestive level
of necrosis
Tends to be more common in
regions of the lung that are
not gravity dependent
Septic emboli Central venous catheters, Multiple, bilateral, Positive blood cultures
pacemakers, right-sided peripherally located Leukocytosis, elevated ESR
prosthetic valves, IV drug nodules that cavitate; and CRP level
abuse, and Lemierre usually seen in different
syndrome stages of cavitation
Fevers, dyspnea, chest pain, May see a feeding vessel sign
cough may progress to Nodules may be 0.5-3.5 cm.
respiratory failure and septic
shock
Nocardia Patients who have undergone Pulmonary nodules and Positive PCR results with
solid organ or stem cell consolidation, most respiratory sample
transplant who are receiving commonly bilateral Microscopy of respiratory
immunosuppressive therapy Cavitation can occur in sample (gram positive
and patients with AIDS, both nodules and and modified acid fast)
lymphoma, and leukemia consolidation. No zonal
Low-grade fevers, weight loss, predominance
and cough 75% of cases may have
Respiratory failure may occur. crazy-paving appearance
around nodules, cavities,
masses, or consolidations
Nodules may be 0.6-2.9 cm.
Cryptococcus Exposure to aged pigeon Multiple bilateral, peripheral Positive sputum culture
droppings More common in nodules and masses that Positive serum latex
patients who are cavitate agglutination results
immunocompromised Nodules may be 0.7-2.8 cm. Positive for b-D-glucan
Fever, cough, dyspnea,
headache May be
asymptomatic
Coccidioidomycosis Severe disease is common in Focal or multifocal Peripheral eosinophilia
hosts who are consolidation is the most May have positive BAL,
immunocompromised and common finding. Cavities sputum, or lung biopsy
travel to endemic regions are seen in 2%-8% of cultures
(Southwest United States, cases. Positive complement
Mexico, Central and South Phantom infiltrates may be fixation, immunodiffusion,
America). seen. and urine antigen
Profound fatigue, erythema Nodules may be 0.5-3.0 cm.
nodosum or erythema
multiforme, arthralgias,
cough, fever, subacute time
course
(Continued)
TABLE 2 ] (Continued)
Cavity Patient Background Radiographic Findings Laboratory Findings
Invasive pulmonary Prolonged neutropenia, T-cell Solitary or multiple nodules Positive for serum
aspergillosis deficiency, organ transplant with a halo sign, and galactomannan and b-D-
Fevers, cough, dyspnea, 1-2 weeks after the halo glucan
hemoptysis unresponsive to sign appears the nodule Positive for BAL
antibiotics can cavitate leading to an galactomannan
air crescent sign
Also may see pleural-based
wedge-shaped areas of
consolidation
Usually > 1 cm
Mucormycosis Poorly controlled diabetes and Radiographically similar to Organisms in tissue at
immunocompromise IPA histopathologic
Patients are often severely ill, Also may see reversed halo examination
with fevers, cough dyspnea, sign more commonly than Negative for b-D-glucan
and hemoptysis. in IPA
CRP ¼ C-reactive protein; ESR ¼ erythrocyte sedimentation rate; IPA ¼ invasive pulmonary aspergillosis; PCR ¼ polymerase chain reaction.
ground-glass attenuation, frequently well defined, within Central and South America. Infection results from the
which a pattern of interlobular septal thickening can be inhalation of aerosolized spores and occurs in patients
identified, restricted to the area of ground-glass living in endemic regions or traveling to these areas.47
attenuation.33 Pleural effusion has been reported in Risk factors include AIDS, hematologic malignancies,
10% to 36% of cases. There also may be associated
bronchiectasis (40%).34-37 The diagnosis can be made
from microscopic examination of bronchial washings
and BAL with modified acid-fast stain and Gram stain
or positive polymerase chain reaction of the respiratory
sample.38,39
Fungal Pathogens: Cryptococcus neoformans is the most

common Cryptococcus species encountered in the United
States and other temperate climates in the world. It is
considered one of the principal pathogens in humans and
is found in soil and aged pigeon droppings.40 Pulmonary
involvement occurs after inhalation of spores and more
commonly affects individuals who are
immunocompromised.41 Patients typically present with
fever, cough, shortness of breath, chest pain, and headache;
however, some patients may be asymptomatic.42,43
Radiographically, the common manifestation is multiple
bilateral, peripheral nodules and masses, although a
random distribution also has been described. Pulmonary
nodules range in size from 0.7 to 2.8 cm.44 Cavitation,
when present, occurs within nodules or masses and less
commonly in foci of air-space consolidation, especially in
hosts who are immunocompromised.42,45 Sputum culture,
b-D-glucan and serum latex agglutination test results may
be positive.46
Figure 7 – Axial CT scan obtained in 42-year-old man demonstrating
Coccidioidomycosis is caused by the fungus an irregular thick-walled cavity with dependent air-fluid level and
peripheral ground-glass halo involving the posterior segment of the right
Coccidioides. This organism is endemic in the soil of the upper lobe and superior segment of the right lower lobe. Biopsy results
southwestern United States, parts of Mexico, and helped confirm abscess, but a specific pathogen was not isolated.

Figure 8 – A-D, Necrotizing pneumonia. Axial CT scans (A, B) of the right lung with lung and soft-tissue windows. There is a large area of consolidation
with surrounding ground-glass opacity and septal thickening in the right lower lobe. Areas of lucency within the consolidation are consistent with
cavitation. No pathogen was identified. C, Acute necrotizing pneumonia (hematoxylin-eosin, 1 magnification). Low-power image shows cavitation at the
bottom of the image surrounded by marked acute inflammation. D, Acute necrotizing pneumonia (hematoxylin-eosin, 10 magnification). A neutrophilic
abscess at the bottom center of the image is surrounded by marked acute and chronic inflammation with a few giant cells.
Figure 9 – A, Necrotizing pneumonia. Axial contrast-material-enhanced CT scan obtained in the mediastinal window in a 74-year-old woman who
presented with shortness of breath, lethargy, and septic shock. Stenotrophomonas and methicillin-sensitive Staphylococcus aureus were in sputum.
There is dense consolidation in both lower lobes, with cavitation and nonenhancing lung (arrow) in the right lower lobe. B, Necrotic lung mass. Axial
contrast-material-enhanced CT scan obtained in the mediastinal window in a 62-year-old woman with lung, skin, liver, and joint involvement from
granulomatosis with polyangiitis. A lung mass with a central area of nonenhancing lung (red arrow) is surrounded by a rim of enhancement (yellow
arrow), suggesting necrosis. A nodule with a similar appearance is posterior to the lung mass with a central area of nonenhancing lung surrounded by a
rim of enhancement.
Figure 10 – A-B, Septic emboli. Coronal (A) and axial (B) scans obtained with lung windows demonstrate multiple nodules in different stages of
cavitation in both lungs. Ground-glass opacity surrounds the cavity in the left apex. A feeding vessel sign (arrow) is visible adjacent to that cavity as
well. Note the right-sided central line.
pregnancy, diabetes, cardiopulmonary disease, smoking, Pulmonary nodules are another common feature and are
and male sex. In primary coccidioidal infection (acute), similar in size to the nodules seen with Cryptococcus.
the majority of patients (60%-80%) are either Cavities are seen in 2% to 8% of acute primary
asymptomatic or have mild influenza-like symptoms. infections. These tend to resolve spontaneously but can
Others will develop symptoms similar to an acute persist to become chronic cavities. Another feature is
bacterial pneumonia such as cough, fever, and chest phantom infiltrates in which parenchymal consolidation
pain. In highly endemic areas, up to 29% of patients with appears at one site, resolves, and then reappears in a new
community-acquired pneumonia have location.52 A peripherally located cavity can rupture into
coccidioidomycosis.48 Some distinguishing features are the pleural space causing a pneumothorax (Fig 12).52
profound fatigue, erythema nodosum or erythema Diagnostic tests include complement fixation,
multiforme, arthralgias, and subacute time course.10,49-51 immunodiffusion, and urine examination for fungal
The most common radiographic manifestation of the antigen.53,54
acute form is focal or multifocal consolidation.
Aspergillus is a commonly found environmental mold
that can cause a variety of pulmonary diseases, including
aspergilloma, chronic necrotizing aspergillosis (CNA),
and invasive pulmonary aspergillosis (IPA). In the host
who is immunocompromised, inhaled Aspergillus can
invade the vasculature, with subsequent infarction and
tissue necrosis. IPA is seen primarily in patients with
prolonged neutropenia, solid organ transplants, or T-cell
deficiencies. Other risk factors include COPD, long-term
steroid therapy, diabetes, and liver cirrhosis.55
Symptoms of pneumonia, including productive cough,
dyspnea, chest pain, hemoptysis, and fevers
unresponsive to antibiotics, are typical. Laboratory test
result abnormalities may include a finding positive for
Figure 11 – Pulmonary Nocardia. Axial CT scan obtained with lung galactomannan and b-D-glucan.56 A number of imaging
windows in a 62-year-old man receiving long-term steroid therapy for findings have been reported to occur due to infection
polymyalgia rheumatica hospitalized for recurrent cough, fevers, and
night sweats demonstrates an area of consolidation with central cavi- with Aspergillus. Of these, acute cavitation is most likely
tation in the right upper lobe. There is a small adjacent ground-glass to be identified in its invasive form. IPA
opacity.

Figure 12 – A-B, Chest radiograph (A) and axial CT scan (B) obtained in 22-year-old man initially thought to have a spontaneous pneumothorax.
Radiographs and CT scans demonstrated a hydropneumothorax in the right lung and a solitary thick-walled cavity at the right apex. Wedge resection
demonstrated granulomatous inflammation, and Coccidioides immitis and C posadasii were identified with sputum culture and polymerase chain
reaction.
Figure 13 – A-B, Axial CT scan (A) demonstrates multiple solid nodules surrounded by ground-glass opacities or ill-defined fuzzy margins—the halo
sign. Coronal high-resolution CT scan (B) demonstrates a crescentic lucency surrounding the nodule—the air crescent sign. This image is from a
different patient from the patient in Figure 13A.
characteristically manifests with multiple pulmonary with a smoking history, older age, and a personal or
nodules, often > 1 cm,57 associated with a halo sign family history of cancer. If the clinical context suggests a
(Fig 13A), which is defined as ground-glass attenuation chronic infection, see step 5. If the clinical context
surrounding a solid central core; the ground-glass suggests malignancy, see step 6. Chronic infections are
component represents pulmonary hemorrhage due to summarized in Table 3; malignancy is summarized
the angioinvasive nature of Aspergillus. One to 2 weeks in Table 4.
after the halo sign appears, especially following
Autoimmune disorders are suggested by a history of
successful treatment, nodules cavitate in up to 63% of
connective tissue disease, arthralgias, myalgias, and
patients, leading to an air crescent sign, as a result of
positive serologic test results. If the clinical context
tissue necrosis (Fig 13B).56,58,59 Another radiographic
suggests autoimmune disorders, see step 7. Autoimmune
appearance of IPA includes pleura-based wedge-shaped
disorders are summarized in Table 5.
areas of consolidation whose findings correspond to
hemorrhagic infarcts.58
Step 5: Chronic Infections
Mucormycosis is an infection caused by molds belonging Mycobacterial Disease: TB is caused by M tuberculosis.
to the order Mucorales. Rhizopus and Mucor are the two In more than 90% cases, it is a reactivation of a latent
genera most commonly noted to cause infection. These infection. The risk of conversion to active disease is
molds are ubiquitous and are found in soil and decaying estimated to be up to 10% through a patient’s entire
plant material. They gain access to the host via inhalation, lifetime and is higher in patients who are
skin penetration, and less frequently ingestion. The most immunocompromised.66,67 Patients with pulmonary TB
frequently affected are those with poorly controlled can present with chronic cough, sputum production,
diabetes and those who are immunocompromised.60 weight loss, fevers, night sweats, loss of appetite, and
Patients are often severely ill and present with fevers, hemoptysis. These patients may have HIV coinfection or
cough, dyspnea, pleuritic chest pain, and hemoptysis. At come from an endemic region.68 Patients with
laboratory analysis, a positive b-D-glucan result is not tuberculosis may have a positive interferon gamma
found because Mucor and Rhizopus do not produce this release assay, tuberculin skin test, or sputum microscopy
polysaccharide. A diagnosis is usually made by means of or culture.65,68 Radiographically, fibrocavitary disease
histopathologic testing.10,61 Radiographically, the occurs in approximately 50% of patients with
manifestation overlaps with that of IPA. More commonly reactivation TB and is seen more often in the apical and
than in IPA, a reversed halo sign may be seen, which is posterior segments of the upper lobes or the superior
defined as curvilinear solid density surrounding a core of segments of the lower lobes. Fibrocavitary disease is
ground-glass attenuation (Fig 4).62 As with IPA masses, defined radiographically as pulmonary infiltrates
nodules, a halo sign, consolidation, and cavitation are all characterized by nodular densities, linear fibrous scars,
seen.61,63,64 Cavity formation can occur after the reversed volume loss due to scarring, and cavitation.68 Multiple
halo sign or halo sign is noted.64,65 Although neither the cavities usually are present and appear thick walled with
halo nor the reversed halo sign is pathognomonic of IPA irregular inner margins, which can become thin and
or mucormycosis, their presence is sufficiently suggestive, smooth with treatment (Fig 2).69-71
especially in the setting of a host who is
immunocompromised, to warrant initial empiric therapy. Nontuberculous mycobacteria (NTM) are ubiquitous in
the environment, but concentrations are highest in water
Step 4: Chronic Cavities ($ 12 Weeks in Duration) and soil. The most common organism associated with
pulmonary disease is Mycobacterium avium complex
The differential diagnosis includes chronic infections,
(MAC), a term that encompasses many subspecies. To
malignancy, and autoimmune disorders. On the
date, two distinct populations of patients have been
basis of the clinical context, we can direct our
identified as frequently infected. The first group is
differential diagnosis into one of these three disease
defined by underlying risk factors that include profound
categories.
immunosuppression such as HIV; transplant; or
Chronic infections and malignancy are suggested by structural lung disease with architectural distortion such
fevers, weight loss, chronic cough, hemoptysis, and as COPD, silicosis, prior TB infection, or cystic
fatigue. However, malignancy is more likely in a patient fibrosis.72-74 Patients in this setting can present with

TABLE 3 ] Chronic Infection
Chronic Infection Patient Background Radiographic Findings Laboratory Findings
Mycobacterium HIV, from endemic region, Cavitation often occurs in the Positive TST or IGRA results
tuberculosis exposure history apical and posterior Positive sputum microscopy
Chronic cough, weight loss, segments of the upper and culture results
fevers, night sweats, lobes and superior
hemoptysis segments of lower lobes.
Solitary or multiple cavities
with thick, irregular walls
usually are present.
Nontuberculous Structural lung disease, Solitary or multiple Positive sputum microscopy
mycobacteria immunosuppressed fibrocavitary changes and and culture results
Chronic cough, hemoptysis, nodules primarily in the
fatigue, weight loss upper lobes
Middle-aged to elderly women Typically involves the right Positive sputum microscopy
without structural lung middle lobe and lingula and culture results
disease with nodules and
Chronic nonproductive cough bronchiectasis
Also may see atelectasis,
consolidation with tree-in-
bud and ground-glass
opacities
Frank cavitation can occur
Chronic necrotizing Structural lung disease, inactive Unilateral or bilateral Positive for Aspergillus IgG
aspergillosis or previously treated MTB, cavitary lesions in upper Positive sputum Aspergillus
prior lung resection, radiation lobes with adjacent pleural PCR results
therapy, cystic fibrosis, or thickening, which may
lung infarction progress to form a
Fevers, cough, dyspnea, bronchopleural fistula
malaise, hemoptysis One-half of these cavities
can develop an
aspergilloma.
Histoplasmosis Ohio and Mississippi River Cavities can be solitary or Positive complement fixation
valleys, exposure to soil that multiple, typically located titers
contains large amounts of bird in the upper lobes and Positive sputum fungal stain
or bat droppings, chicken associated with fibrosis. and culture results
coops, more common in those Also may see punctate Histoplasma antigen in
with structural lung disease calcifications in the spleen, urine, blood, and BAL
Productive cough, fever, night liver, and mesenteric
sweats, weight loss, erythema lymph nodes
nodosum, erythema
multiforme
Blastomycosis United States and Canada Cavities are uncommon but Potassium hydroxide smear
surrounding the Ohio and can be solitary or multiple, of fresh sputum frequently
Mississippi River valleys and typically located on the will indicate the organism.
the Great Lakes upper lobes, and have thin Positive urine, serum, or BAL
More commonly affect the host or thick walls. antigens are helpful
who is immunocompetent
Cough, fever, night sweats,
malaise, skin and bone
involvement
Paragonimus Ingestion of raw freshwater crab Nodules with cavitation Characteristic eggs at
or crayfish Nodule size is most sputum or BAL testing
Endemic to Japan, China, Korea, commonly 2.0 cm. Peripheral eosinophilia may
and the Philippines be seen.
Productive cough, chest pain,
back pain, fevers
(Continued)
TABLE 3 ] (Continued)
Chronic Infection Patient Background Radiographic Findings Laboratory Findings
Echinococcus South America, countries Majority of lesions are liver Serologic testing
surrounding the cysts, but lung is involved Peripheral eosinophilia may
Mediterranean, the Middle 20%-30% of the time. be seen.
East, some sub-Saharan Pulmonary cavities may
African countries form. Cavity wall may
Often asymptomatic for years, calcify over time.
may develop fevers, cough, Collapsed laminated
hemoptysis, wheezing, membrane may float in the
anaphylaxis, or cavity, producing the
pneumothorax water lily sign.
Tracheobronchial Human papillomavirus, multiple Mucus plugging with finger- Bronchial tree tissue biopsy
papillomatosis papillomas in the in-glove appearance,
nasopharynx, larynx, and atelectasis, sold and
bronchial tree cavitary nodules
Nodules are 0.5-5 cm.
IGRA ¼ interferon gamma release assay; MTB ¼ Mycobacterium tuberculosis; TST ¼ tuberculin skin test. See Table 2 for expansion of other abbreviation.
chronic productive cough, hemoptysis, malaise, fatigue, Fungal Disease: CNA is an indolent, destructive process
and weight loss. Patients with NTM may have positive due to Aspergillus species in the lung, which can be
sputum microscopy or culture results. Radiographically, differentiated from IPA because of its chronicity
MAC appears similar to reactivation TB, with upper (months to years).60 These patients will present with
lobe fibrocavitary disease (Figs 14A-D); however, fever, cough, sputum production, dyspnea, hemoptysis,
cavities due to MAC may be smaller or thin walled, and anorexia, weight loss, and malaise. Almost all patients
disease may progress more slowly. Common associated with CNA have underlying structural lung disease such
imaging findings include tree-in-bud opacities and as COPD, inactive or previously treated TB, prior lung
bronchiectasis.75-77 resection, radiation therapy, cystic fibrosis, or lung
infarction.60,79 The most sensitive laboratory test is an
A second group of individuals at risk for NTM infection
Aspergillus IgG antibody. With sputum, Aspergillus
are elderly women who present with chronic
polymerase chain reaction testing is more sensitive than
nonproductive cough and weight loss. This group tends
culture.80 Radiographically, Aspergillus manifests as
to present primarily with signs of chronic airway
unilateral or bilateral cavitary lesions in the upper lobes
inflammation, including bronchiectasis and small
associated with adjacent pleural thickening, which may
airway disease manifesting as branching centrilobular or
progress to a bronchopleural fistula. Approximately
tree-in-bud opacities. Although these findings may
one-half of these cavities can develop an aspergilloma
occur anywhere throughout the lung, a particularly
(Fig 15).56,60,62,81,82
distinct pattern is the predominant involvement of the
lingula and middle lobe (Figs 14E-G). In more extensive Histoplasmosis is caused by the dimorphic fungus
cases, frank cavitation may occur.78 Histoplasma capsulatum. The fungus typically lives in
TABLE 4 ] Malignancy
Malignancy Patient Background Radiographic Findings Laboratory Findings
Primary Smoking history, family history of lung Irregular internal wall Tissue at histopathologic
cancer, and asbestos exposure Usually solitary with an upper lobe examination
Cough, weight loss, malaise, predominance
hemoptysis
Metastatic Extrathoracic malignancy (commonly Multiple bilateral pulmonary Tissue at histopathologic
squamous cell) and smoking history nodules, which can cavitate and examination
Cough, weight loss, malaise, vary from irregular and thick to
hemoptysis regular and thin
May see Cheerios sign

TABLE 5 ] Autoimmune Disorders
Autoimmune Disorder Patient Background Radiographic Findings Laboratory Findings
Rheumatoid arthritis History or symptoms of Well-defined nodules of a Elevated rheumatoid
rheumatoid arthritis, few millimeters to a few factor level
including joint pains and centimeters with central Elevated anti-CCP
fevers cavitation and sometimes antibody level
seen with the underlying Elevated ESR or CRP level
background of interstitial
lung disease
Granulomatosis with History of granulomatosis Multiple and bilateral Elevated serum
polyangiitis with polyangiitis pulmonary nodules cytoplasmic anti-
May have symptoms Cavitation can occur in 25%- neutrophil antibodies
including rhinosinusitis, 50% of nodules that are against proteinase 3 in
epistaxis, fever, malaise, usually thick walled. cytoplasmic granule
hemoptysis titers
Anti-CCP ¼ Anti-cyclic citrullinated peptide. See Table 2 legend for expansion of other abbreviations.
soil that contains large amounts of bird or bat have had symptoms of productive cough, malaise, fevers,
droppings. In the United States, Histoplasma is endemic night sweats, and weight loss. Less common symptoms
around the Ohio, Missouri, and Mississippi River valleys include chest pain due to mediastinal lymph node
and St. Lawrence River area.82 Patients with structural enlargement, arthralgias, arthritis, erythema nodosum,
lung disease such as COPD are at risk and typically will and erythema multiforme.83 Positive complement
Figure 14 – A-G, Nontuberculous mycobacteria. Axial (A, B) and coronal (C) CT scans obtained in a 68-year-old woman with sputum culture-positive
nontuberculous mycobacteria demonstrating thick-walled cavities, bronchiectasis (arrow in B), bronchial wall thickening (arrow in A and C), and
several tree-in-bud opacities in the right lower lobe. Coronal CT scan (D) demonstrates fibrocavitary disease in the lung apexes bilaterally, with traction
of the hila and fissures (arrows) superiorly. Axial CT scans (E, F, G) demonstrate multiple thick-walled cavities confined to the right lung with tree-in-
bud opacities bilaterally.
Figure 15 – A-C, Aspergilloma. Axial CT scan (A) demonstrates solid masses in dependent positions within biapical cavities, consistent with fungus
balls. B, Bronchiectasis with aspergilloma (hematoxylin-eosin, 2 magnification). This image shows a markedly dilated cavitary airway surrounded
by acute and chronic inflammation and a thick rim of fibrosis. This pathology slide is from a different patient from the radiographic image of
Figure 15A. C, Bronchiectasis with aspergilloma (Gomori methenamine silver, 20 magnification). This image shows a fungus ball within the airway
with the morphology of the Aspergillus species. The fungal organisms are highlighted by the Gomori methenamine silver stain. This pathology slide is
from a different patient from the radiographic image of Figure 15A.
Figure 16 – A-C, Histoplasmosis. Axial high-resolution CT scan (A) demonstrates a thick-walled, cavitary nodule with eccentric calcification in the
right upper lobe. Coronal CT scan (B) obtained with a mediastinal window demonstrates large calcified lymph nodes in the right hilum and a thick-
walled, cavitary nodule (arrow) with eccentric calcification in the right upper lobe. Coronal CT scan (C) obtained with a mediastinal window
demonstrates multiple punctate calcifications in the spleen.

fixation titer and sputum fungal stain and culture results in the upper lobes (Fig 17C), and can result in
and positive Histoplasma antigen in urine, blood, and posttreatment scarring.94
BAL all support the diagnosis.84,85 Radiographically,
Parasitic Diseases: Paragonimiasis is a food-borne
cavities typically are found in the upper lobes, and
illness caused by the lung fluke Paragonimus
associated fibrosis can be seen in up to 30% of patients
westermani and is associated with the ingestion of raw
(Fig 16A).86-88 Findings of numerous punctate
freshwater crab or crayfish. The majority of cases occur
calcifications in the spleen, liver, and mesenteric lymph
in Asia, although some cases have been acquired in the
nodes are particularly suggestive signs of previous
United States.92,95 Productive cough, chest pain, back
histoplasmosis (Figs 16B and 16C).89 In
pain, fever, and dyspnea are common; however, some
contradistinction, although TB also may result in splenic
patients can be asymptomatic.96 At laboratory testing,
and hepatic calcifications, these are characteristically far
an elevated blood eosinophil count and visualization of
less numerous.
eggs on BAL can be seen.97 Radiographically, nodules
Blastomycosis is caused by Blastomyces dermatitidis and, are common, with cavitation noted in 15% to 59% of
similar to Histoplasma and Coccidioides, lives in the soil, cases.1 In one series, the most common nodule size was
particularly in moist soil. It typically is found only in the 2 cm.98
United States and Canada surrounding the Ohio and
Mississippi River valleys and the Great Lakes. Echinococcosis results from infection with Echinococcus
Pulmonary blastomycosis occurs when the fungus from granulosus, a tiny tapeworm found in dogs (the
the soil is inhaled.90 More commonly seen in a host who definitive hosts.) Echinococcosis is found in Africa;
is immunocompetent, these patients are often Europe; Asia; the Middle East; Central and South
asymptomatic. In those who develop symptoms, the America; and, in rare cases, North America.99 Patients
illness begins about 30 to 45 days after exposure, with are often asymptomatic for years; however, if signs or
cough, fevers, night sweats, weight loss, and malaise symptoms develop, chest pain, cough, hemoptysis, or
being common. Skin is the most common pneumothorax are seen. Patients also may develop
extrapulmonary site of infection. It often begins with a wheezing, fever, urticaria, and anaphylaxis if antigenic
papulopustular lesion that progresses to ulcerative, material is released from a cyst.99 Laboratory analysis
verrucous, or crusted lesions (Figs 17A and 17B). The may reveal peripheral blood eosinophilia and positive
bone is the second most common extrapulmonary site of serologic test results.98,100 Radiographically, liver cysts
infection, and most patients with osteomyelitis have are the most common finding; however, 20% to 30% of
concomitant pulmonary blastomycosis.91 Patients may cases develop lung cysts. If air enters the ruptured cyst, it
have positive sputum smears; cultures; or urine, serum, can appear as a crescent-shaped lucency or have a
or BAL Blastomyces antigen.93 Radiographically, cavitary appearance. There also may be evidence of a
cavitation occurs less frequently in blastomycosis than in collapsed laminated membrane that may float in the
histoplasmosis and TB. Cavities can have thin or thick cavity, producing the water lily sign (Fig 18).36
walls, be single or multiple, are more commonly located Eventually, the cavity wall calcifies.1,99
Figure 17 – A-C, Photograph (A) shows two hyperkeratotic verrucous papules (arrow) in a patient with cutaneous blastomycosis. Photograph (B) shows
discrete hyperkeratotic ovoid pink plaque (arrow) in a patient with cutaneous blastomycosis. Axial CT scan (C) obtained in a 53-year-old man, a
current smoker with a history of diabetes with cavitary blastomycosis, demonstrates multiple cavitary lesions bilaterally, along with additional
scattered, ill-defined, small air-space opacities throughout the lung, most prominent in the upper lobes.
Woodring et al106,107 suggested that the maximum wall
thickness of the cavity can help differentiate between
malignant and nonmalignant causes, with a maximum
wall thickness > 15 mm indicating malignancy in more
than 90% cases. However, these studies looked at plain
chest radiographs rather than CT scans. A more recent
study evaluating cavity maximum wall thickness on
chest CT scans did not find a difference between
malignant and nonmalignant causes; however, it
appeared that malignant cavities were more likely to
have an irregular internal wall (49% vs 26%) and have
an indentation of the outer wall of the cavity
(54% vs 29%) as compared with a benign cavity
(Fig 20).108 There is an upper lobe predominance.109
Figure 18 – Axial high-resolution CT scan obtained in a 37-year-old Diagnosis is made by means of histopathologic testing.
woman admitted for treatment of Echinococcus pneumonia demon-
strates a thick-walled cavity with collapsed laminated membrane—the
The most common type of primary cavitary lung cancer
water-lily sign (arrow). There is dense consolidation anterior to the is non-small cell lung cancer, especially squamous cell
cavity. carcinoma (69%-81%).107,108 Adenocarcinomas, large
cell carcinomas, and small cell carcinomas are unlikely
to cavitate.72 Primary or secondary pulmonary
Viral Infections: Human papillomavirus can cause
lymphoma has a broad spectrum of appearances,
tracheobronchial papillomatosis. Chronic infection
including consolidation, masses, and cavitating
with H papillomavirus may result in multiple
nodules.110
papillomas within the nasopharynx, larynx, or
tracheobronchial tree. Respiratory papillomas may Pulmonary metastases, most often from squamous
undergo malignant transformation to squamous cell primaries such as head and neck, cervical, skin, or
carcinoma in 3% to 5% of patients.101 Radiographic sarcomas, also may cavitate. The radiographic
features include mucous plugging with finger-in-glove morphology of these cavities varies from thick and
appearance, atelectasis, and solid cavitary nodules irregular to very smooth and thin, simulating a cyst.72,111
(Fig 19). Diagnosis is made by means of transbronchial Rarely, metastatic disease leads to the Cheerio sign,
biopsy.100,102 Pulmonary nodules range from 0.5 to defined as multiple tiny cavitary nodules typically only a
5 cm in size.103 few millimeters in size, most often associated with GI
malignancies (Fig 21).36
Step 6: Malignancy
Cavities are found relatively frequently in primary lung Step 7: Autoimmunity
cancer, with an incidence of up to 11% on plain chest Rheumatoid arthritis (RA) is a systemic autoimmune
radiographs104 and up to 22% on CT scans.105 disorder characterized by synovial inflammation,
auto-antibody production, cartilage and bony
destruction, and common pulmonary complications.112
Fifty percent to 80% of patients with RA will have a
positive rheumatoid factor, anti-cyclic citrullinated
peptide antibody, or both.113 Common pulmonary
findings include interstitial lung disease (ILD), pleural
disease, and rheumatoid nodules. Rheumatoid nodules
are found in 20% of patients and radiographically
appear as multiple well-defined nodules, a few
millimeters to a few centimeters in size. These nodules
occasionally develop central necrosis (Fig 22). A
background of underlying ILD may help with the
Figure 19 – Axial CT scan demonstrates a thick-walled cavity with an diagnosis.114,115 A variety of ILD patterns is seen on
irregular nodular margin due to tracheobronchial papillomatosis. high-resolution CT scans in RA; however, the usual

Figure 20 – A-B, Squamous cell carcinoma of the lung. Axial (A) and coronal (B) CT scans demonstrate a thick-walled cavitary mass (arrows) in the
left upper lobe. The internal walls of the cavity are irregular.
Figure 21 – A-C, Axial (A) and sagittal (B) high-resolution CT scans obtained in a 36-year-old man with a history of autoimmune pancreatitis with a
diagnosis of metastatic adenocarcinoma of the pancreas demonstrate innumerable randomly distributed cavitary nodules with basilar predominance.
Axial PET/CT scan (C) through the lung bases. There is diffuse abnormal activity throughout both lungs, greatest in the lung bases. Biopsy results
helped confirm pulmonary metastatic disease from pancreatic cancer.
interstitial pneumonia pattern is seen most frequently
(40%-62% of cases). In usual interstitial pneumonia,
high-resolution CT scans show subpleural, basilar-
predominant reticular abnormalities with
honeycombing and traction bronchiectasis.113 Pleural
effusions are noted in up to 70% of patients at autopsy;
however, only 3% to 5% of patients have symptoms.116
Because both RA and lung cancer are associated with
cigarette smoking, a cavitary lung cancer always should
be in the differential diagnosis.
Granulomatosis with polyangiitis (GPA) is a systemic
autoimmune disease characterized by necrotizing
granulomatous inflammation and vasculitis of the upper
and lower respiratory tract and kidneys.117,118 Patients
Figure 22 – Axial CT scan obtained in a 45-year-old woman, a former
smoker with a 30-year history of rheumatoid arthritis and incidental
with GPA can present with fever, malaise, night sweats,
pulmonary nodules, demonstrates an irregular, lobulated, and spicu- anorexia, dyspnea, cough, purulent nasal discharge,
lated cavitary nodule in the left upper lobe. Surgical biopsy results helped epistaxis, and hemoptysis.119 Anti-neutrophil
confirm a rheumatoid nodule.
cytoplasmic antibody positivity occurs in up to 90% of
patients with severe systemic disease and in up to
Figure 23 – A-C, High-resolution CT scan (A) obtained in a 73-year-old man with a history of pyoderma gangrenosum and with granulomatosis with
polyangiitis proved by means of pathologic testing demonstrates multiple bilateral cavitary masses and nodules. The larger, more anterior lesion in the
right upper lobe has a dependent air-fluid level. B, Granulomatosis with polyangiitis (hematoxylin-eosin, 1 magnification). This image shows a
cavitary granulomatous lesion in a patient with clinical granulomatosis with polyangiitis. This cavitary lesion is surrounded by granulomatous
inflammation and vasculitis. This pathology slide is from a different patient from the radiographic image in Figure 23A. C, Granulomatosis with
polyangiitis (hematoxylin-eosin, 4 magnification). This image shows a cavitary granulomatous lesion in a patient with clinical granulomatosis with
polyangiitis. This area shows geographic necrosis surrounded by granulomatous inflammation. This pathology slide is from a different patient from the
radiographic image in Figure 23A.

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[ Special Features ]

Cavitary Lung Diseases

1444 Special Features [ 153#6 CHEST JUNE 2018 ]

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Step 5 Step 6 Step 7

Acute infections Chronic Infections Malignancy Autoimmunity

Clinical History & Investigations: Clinical History & Investigations:

CT features CT features CT features CT features

See Table 2 See Table 3 See Table 4 See Table 5

Emphysema Focal areas or regions of low

Infected bullae Radiographic evidence of previous

Cystic bronchiectasis Lack of bronchial tapering and an

1448 Special Features [ 153#6 CHEST JUNE 2018 ]

Fungal Pathogens: Cryptococcus neoformans is the most

1450 Special Features [ 153#6 CHEST JUNE 2018 ]

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1460 Special Features [ 153#6 CHEST JUNE 2018 ]

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1464 Special Features [ 153#6 CHEST JUNE 2018 ]

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