lungs Fx 1 opacity subsegmental RUL 2 combination consolidation GGO atelectasis Dx DDx bronchopneumonia CT 74F Cough fever

Lungs

74Fyear old female presents with a cough and fever

2. Findings and Diagnosis

74 year old female presents with a cough and fever

CT scan of a 74 year old febrile female showing a wedge shaped right upper lobe opacity consisting of a combination of consolidation and ground glass components along a bronchovascular distribution consistent with bronchopneumonia. An enlarged right hilar lymph node is present
Ashley Davidoff TheCommonVein.net RnD Image First program

CT of the chest in a 74-year-old female with fever and cough shows a focal, wedge-shaped opacity in the subsegmental region of the right upper lobe.

Ashley Davidoff MD, TheCommonVein.com (135180.bronchopneumonia)

Table 1 – Observations

Observation	Description
Composite opacity – RUL	Patchy opacity centered in the right upper lobe
Posterior segment location	Gravity-dependent area → favors aspiration etiology in supine elderly
Bronchovascular bundle	Opacity aligned with branching airways and vessels
Focus 1: Consolidation	Homogeneous increased attenuation
Focus 2: Ground-glass opacity	Hazy attenuation with preserved bronchovascular markings
Focus 3: Atelectasis	Volume loss seen as fissure crowding and bronchial narrowing

Table 2 – Explanation of Radiologic Terms

Term	Definition
Opacity	Nonspecific increased attenuation on CT; reflects underlying parenchymal abnormality
Bronchovascular bundle	Anatomic unit comprising a bronchus and accompanying vessels
Consolidation	Alveolar spaces filled with fluid, pus, or cells; obscures vessels and airways
Ground-glass opacity	Partial alveolar/interstitial involvement with preserved parenchymal structure visibility
Atelectasis	Collapse of alveoli with associated volume loss and crowding of adjacent anatomy

Table 3 – Associated Findings

Associated Fx (Imaging or Clinical Context)	Relevance to Dx
Fever and productive cough	Clinical indicators of lower respiratory tract infection
Posterior RUL location	Dependent zone → aspiration pneumonia favored in elderly/supine states
Segmental pattern along bronchovascular tree	Consistent with bronchopneumonia via bronchogenic spread
Air bronchograms	Confirm alveolar space involvement typical of infection

Table 4 – Classification of the Primary Finding (Opacity)

Type of Opacity	Description
Consolidation	Alveolar filling; obscures normal vessels and airways
Ground-glass opacity	Partial alveolar/interstitial filling; vessels still visible
Atelectasis	Collapse with loss of volume and adjacent structure crowding
Mixed Opacity	Multiple overlapping patterns typical of bronchopneumonia

Table 5a – Differential Diagnosis: Most Likely

Disease Category	Specific Diagnosis
Infectious	Aspiration pneumonia
Infectious	Bronchopneumonia (typical bacterial)
Infectious	Atypical pneumonia (e.g., Mycoplasma, Chlamydia)

Table 5b – Differential Diagnosis: Other Possibilities

Disease Category	Specific Diagnosis
Infection	TB (non-cavitary upper lobe infiltrate)
Neoplasm – Malignant	Pneumonic-type adenocarcinoma
Neoplasm – Benign	Inflammatory pseudotumor
Infiltrative	Cryptogenic organizing pneumonia (COP)
Inflammation Immune	Eosinophilic pneumonia
Mechanical	Post-obstructive pneumonia
Iatrogenic	Drug-induced pneumonitis
Idiopathic	Acute interstitial pneumonia

Table 6 – Radiologic Strategy & Guidelines

Modality	Name of Guideline	Reference with URL
CXR	First-line pneumonia detection	ACR Appropriateness Criteria – Acute Respiratory Illness – https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/Acute-Respiratory-Illness.pdf
CT Chest	Evaluation of aspiration or atypical pneumonia	ACR Appropriateness Criteria – Acute Chest Imaging – https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/Acute-Chest.pdf
CT Follow-up	Persistent opacity to rule out hidden mass	Fleischner Society – https://pubs.rsna.org/doi/full/10.1148/radiol.2015150029

Table 7 – Pearls (Imaging & Pattern Recognition)

Pearls
Posterior RUL location + elderly/supine = classic aspiration zone
Mixed opacity (GGO + consolidation + atelectasis) = evolving or resolving bronchopneumonia
Consolidation with air bronchograms is diagnostic of alveolar filling process
Non-resolving opacities may mask malignancy → follow-up CT recommended after 6–8 weeks

3. Clinical

Page 3 – Diagnosis and Clinical Context

Dx Focus:
In this patient, the diagnosis was bronchopneumonia, with a pattern suggesting aspiration pneumonia. The posterior segment of the right upper lobe—a gravity-dependent zone—contained a composite opacity characterized by consolidation, ground-glass attenuation, and volume loss, consistent with alveolar infection, partial filling, and atelectasis. The clinical setting of cough and fever in an elderly patient further supports an infectious etiology with aspiration physiology likely.

Table – Clinical Perspective

Element	Detail
Definition	Bronchopneumonia is a patchy infection of the lung, often involving multiple lobules or segments, and characterized by bronchogenic spread of pathogens into the alveolar spaces
Caused by	Common pathogens include Streptococcus pneumoniae, Staphylococcus aureus, Klebsiella, anaerobes (in aspiration), Mycoplasma, and viruses
Pathophysiology and Pathogenesis	Inhalation or aspiration of organisms → infection spreads via airways to alveoli → inflammation, exudation, and impaired gas exchange
Structural Changes	Focal consolidation, GGO, and atelectasis; often patchy and non-lobar
Functional Impact	Reduced ventilation in affected segments, V/Q mismatch, and hypoxemia
Clinical Presentation	Cough, fever, dyspnea, sometimes pleuritic chest pain; aspiration may be silent
Labs	Leukocytosis, elevated CRP/procalcitonin, sputum or blood cultures; possibly aspiration risk factors
Treatment	Empiric antibiotics (e.g., ampicillin-sulbactam or ceftriaxone + metronidazole), supportive oxygen
Prognosis	Good in healthy individuals; worse in elderly or those with comorbidities; aspiration ↑ recurrence risk

Table – Pearls (Clinical Focus)

Pearls
Consolidation + posterior segment → suspect aspiration in elderly or bed-bound patients
Air bronchogram = alveolar space infection, not mass
Consider anaerobes or mixed flora if aspiration likely
If opacity persists beyond treatment window, investigate for hidden malignancy or chronic infection

4. Historical and Cultural

Table 1 – Etymology

Term	Origin and Meaning
Pneumonia	From Greek pneumon = lung + -ia = condition → inflammation of the lungs
Aspiration	Latin aspirare = to breathe toward or into; in medicine, refers to inhalation of substances into airways

Table 2 – History in Medicine

Category	Detail
Anatomy	Early lung structure descriptions trace back to Galen; later clarified by Vesalius in the Renaissance
Physiology	Discovery of air-blood gas exchange by William Harvey and further explored by Lavoisier
Clinical Medicine	Pneumonia identified as a leading infectious cause of death by William Osler in the early 1900s
Diagnosis	Radiologic detection of pneumonia advanced after Röntgen’s 1895 discovery of X-rays
Treatment	Antibiotics revolutionized care post-World War II; aspiration pneumonia recognized as distinct subtype in mid-20th century

Table 3 – Culture and Art

Category	Detail
Cultural Insights	Pneumonia historically called the “old man’s friend” due to its high fatality and often peaceful end-stage course
Metaphorical Imagery	Aspiration pneumonia = “a drowning from within”—where food or fluid quietly suffocates the lungs
Sociomedical Beliefs	In some cultures, coughing after eating is considered a sign of spiritual weakness or imbalance
Artistic References	Medical illustrations often depict lungs filling with ink-like fluid to represent infection or drowning
Literature	Tolstoy and Emily Dickinson wrote about slow breathing and death from “consumption” (often TB or pneumonia)
Notable Figures	Wolfgang Amadeus Mozart, Edward Jenner, and Joseph Stalin reportedly died of pneumonia
Historical Patients	Charles Darwin frequently suffered bronchial infections, suspected to be chronic bronchopneumonia
Quotes	“Pneumonia may well be called the captain of the men of death.” – Sir William Osler

5. MCQs

1 (Basic Science)

Which of the following structures most directly protects the airway from aspiration during swallowing?
A. Uvula
B. Tongue
C. Epiglottis
D. Soft palate

Correct Answer Explanation

Correct Answer	Explanation
C	The epiglottis folds over the glottis during swallowing, preventing aspiration.
Reference: Gray’s Anatomy for Students. https://www.elsevier.com/books/grays-anatomy-for-students/drake/978-0-323-39303-3