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Viral Pneumonias in Adults: Radiologic and Pathologic Findings¹

¹ From the Departments of Radiology (E.A.K., K.S.L., H.K.Y., H.S.B., T.S.K.), Medicine (G.Y.S., O.J.K.), and Diagnostic Pathology (J.H.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea; and the Department of Radiology, Oregon Health Sciences University, Portland (S.L.P.). Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received January 29, 2002; revision requested March 14 and received April 10; accepted April 26. Address correspondence to K.S.L. (e-mail: kslee@smc.samsung.co.kr).

View larger version (181K): [in a new window]   Figure 1.  Photomicrograph (original magnification, x100; hematoxylin-eosin stain) of a lung biopsy specimen from a 36-year-old man with pneumonia due to herpes simplex virus type 1 shows a fibrous exudate (large arrows) along the alveolar walls. Note the interstitial thickening due to fibroblastic proliferation (small arrows).

View larger version (132K): [in a new window]   Figure 2a.  Pneumonia due to influenza virus (type C) in a 46-year-old man with dyspnea. (a) Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs. (b) Follow-up chest radiograph obtained 15 days after a shows progression of the extent of disease with diffuse consolidation throughout both lungs. (c) Thin-section (1-mm collimation) computed tomographic (CT) scan obtained 16 days after a at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs. (Case courtesy of Dr Jung Hwa Hwang, Soonchunhyang University Seoul Hospital, Korea.)

View larger version (126K): [in a new window]   Figure 2b.  Pneumonia due to influenza virus (type C) in a 46-year-old man with dyspnea. (a) Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs. (b) Follow-up chest radiograph obtained 15 days after a shows progression of the extent of disease with diffuse consolidation throughout both lungs. (c) Thin-section (1-mm collimation) computed tomographic (CT) scan obtained 16 days after a at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs. (Case courtesy of Dr Jung Hwa Hwang, Soonchunhyang University Seoul Hospital, Korea.)

View larger version (132K): [in a new window]   Figure 2c.  Pneumonia due to influenza virus (type C) in a 46-year-old man with dyspnea. (a) Initial chest radiograph shows diffuse reticulonodular areas of increased opacity in both lungs. (b) Follow-up chest radiograph obtained 15 days after a shows progression of the extent of disease with diffuse consolidation throughout both lungs. (c) Thin-section (1-mm collimation) computed tomographic (CT) scan obtained 16 days after a at the level of the aortic arch shows diffuse ground-glass attenuation with some irregular linear areas of increased attenuation in both lungs. (Case courtesy of Dr Jung Hwa Hwang, Soonchunhyang University Seoul Hospital, Korea.)

View larger version (153K): [in a new window]   Figure 3a.  Pneumonia due to influenza virus in a 21-year-old man with a cough. (a) Initial chest radiograph shows poorly defined nodules (arrows) and reticular areas of increased opacity in both lungs. (b, c) Thin-section (1-mm collimation) CT scans obtained at the levels of the aortic arch (b) and suprahepatic inferior vena cava (c) show multifocal peribronchovascular or subpleural consolidation and ground-glass attenuation in both lungs. Some lesions have a lobular distribution (arrows). Note the acinar nodules (arrowheads). (Case courtesy of Jin Mo Goo, MD, PhD, Seoul National University Hospital, Korea.)

View larger version (125K): [in a new window]   Figure 3b.  Pneumonia due to influenza virus in a 21-year-old man with a cough. (a) Initial chest radiograph shows poorly defined nodules (arrows) and reticular areas of increased opacity in both lungs. (b, c) Thin-section (1-mm collimation) CT scans obtained at the levels of the aortic arch (b) and suprahepatic inferior vena cava (c) show multifocal peribronchovascular or subpleural consolidation and ground-glass attenuation in both lungs. Some lesions have a lobular distribution (arrows). Note the acinar nodules (arrowheads). (Case courtesy of Jin Mo Goo, MD, PhD, Seoul National University Hospital, Korea.)

View larger version (118K): [in a new window]   Figure 3c.  Pneumonia due to influenza virus in a 21-year-old man with a cough. (a) Initial chest radiograph shows poorly defined nodules (arrows) and reticular areas of increased opacity in both lungs. (b, c) Thin-section (1-mm collimation) CT scans obtained at the levels of the aortic arch (b) and suprahepatic inferior vena cava (c) show multifocal peribronchovascular or subpleural consolidation and ground-glass attenuation in both lungs. Some lesions have a lobular distribution (arrows). Note the acinar nodules (arrowheads). (Case courtesy of Jin Mo Goo, MD, PhD, Seoul National University Hospital, Korea.)

View larger version (175K): [in a new window]   Figure 4.  Pneumonia due to measles virus in a 13-year-old boy with a fever, cough, and skin rash. The patient had an increased immunoglobulin M antibody titer to measles virus. Chest radiograph shows poorly defined nodules and patchy consolidation in the left middle and lower lung zones.

View larger version (173K): [in a new window]   Figure 5a.  Pneumonia due to Hantavirus (Sin Nombre species) in a 39-year-old American woman with dyspnea. (a, b) Initial posteroanterior (a) and lateral (b) chest radiographs show bilateral perihilar and basilar ground-glass opacity. Fissures are accentuated on the lateral radiograph (b). The heart is of normal size. (c) Follow-up anteroposterior chest radiograph obtained 4 days after a shows progression to extensive bilateral consolidation in the middle and lower lung zones.

View larger version (153K): [in a new window]   Figure 5b.  Pneumonia due to Hantavirus (Sin Nombre species) in a 39-year-old American woman with dyspnea. (a, b) Initial posteroanterior (a) and lateral (b) chest radiographs show bilateral perihilar and basilar ground-glass opacity. Fissures are accentuated on the lateral radiograph (b). The heart is of normal size. (c) Follow-up anteroposterior chest radiograph obtained 4 days after a shows progression to extensive bilateral consolidation in the middle and lower lung zones.

View larger version (145K): [in a new window]   Figure 5c.  Pneumonia due to Hantavirus (Sin Nombre species) in a 39-year-old American woman with dyspnea. (a, b) Initial posteroanterior (a) and lateral (b) chest radiographs show bilateral perihilar and basilar ground-glass opacity. Fissures are accentuated on the lateral radiograph (b). The heart is of normal size. (c) Follow-up anteroposterior chest radiograph obtained 4 days after a shows progression to extensive bilateral consolidation in the middle and lower lung zones.

View larger version (106K): [in a new window]   Figure 6a.  Pneumonia due to adenovirus in a 15-year-old boy. Thin-section (1-mm collimation) CT scans obtained at the levels of the inferior pulmonary vein (a) and the dome of the liver (b) show complete atelectasis of the right middle lobe and multifocal air trapping (arrows), an appearance indicative of acute bronchiolitis.

View larger version (126K): [in a new window]   Figure 6b.  Pneumonia due to adenovirus in a 15-year-old boy. Thin-section (1-mm collimation) CT scans obtained at the levels of the inferior pulmonary vein (a) and the dome of the liver (b) show complete atelectasis of the right middle lobe and multifocal air trapping (arrows), an appearance indicative of acute bronchiolitis.

View larger version (137K): [in a new window]   Figure 7a.  Pneumonia due to herpes simplex virus type 1 in a 36-year-old man with myelodysplastic syndrome. (a) Initial chest radiograph shows diffuse ground-glass opacity, poorly defined nodules, and patchy consolidation in both lungs. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the inferior pulmonary vein shows diffuse ground-glass attenuation and some air-space nodules (arrows) in both lungs. Note the small bilateral pleural effusions. (c) Photomicrograph (original magnification, x12; hematoxylin-eosin stain) shows diffuse alveolar wall thickening (large arrows) due to fibroblastic proliferation (diffuse alveolar damage, organizing stage). Note the intraalveolar exudate (small arrows). (d) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows eosinophilic inclusions (arrows) within large nuclei.

View larger version (138K): [in a new window]   Figure 7b.  Pneumonia due to herpes simplex virus type 1 in a 36-year-old man with myelodysplastic syndrome. (a) Initial chest radiograph shows diffuse ground-glass opacity, poorly defined nodules, and patchy consolidation in both lungs. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the inferior pulmonary vein shows diffuse ground-glass attenuation and some air-space nodules (arrows) in both lungs. Note the small bilateral pleural effusions. (c) Photomicrograph (original magnification, x12; hematoxylin-eosin stain) shows diffuse alveolar wall thickening (large arrows) due to fibroblastic proliferation (diffuse alveolar damage, organizing stage). Note the intraalveolar exudate (small arrows). (d) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows eosinophilic inclusions (arrows) within large nuclei.

View larger version (182K): [in a new window]   Figure 7c.  Pneumonia due to herpes simplex virus type 1 in a 36-year-old man with myelodysplastic syndrome. (a) Initial chest radiograph shows diffuse ground-glass opacity, poorly defined nodules, and patchy consolidation in both lungs. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the inferior pulmonary vein shows diffuse ground-glass attenuation and some air-space nodules (arrows) in both lungs. Note the small bilateral pleural effusions. (c) Photomicrograph (original magnification, x12; hematoxylin-eosin stain) shows diffuse alveolar wall thickening (large arrows) due to fibroblastic proliferation (diffuse alveolar damage, organizing stage). Note the intraalveolar exudate (small arrows). (d) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows eosinophilic inclusions (arrows) within large nuclei.

View larger version (172K): [in a new window]   Figure 7d.  Pneumonia due to herpes simplex virus type 1 in a 36-year-old man with myelodysplastic syndrome. (a) Initial chest radiograph shows diffuse ground-glass opacity, poorly defined nodules, and patchy consolidation in both lungs. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the inferior pulmonary vein shows diffuse ground-glass attenuation and some air-space nodules (arrows) in both lungs. Note the small bilateral pleural effusions. (c) Photomicrograph (original magnification, x12; hematoxylin-eosin stain) shows diffuse alveolar wall thickening (large arrows) due to fibroblastic proliferation (diffuse alveolar damage, organizing stage). Note the intraalveolar exudate (small arrows). (d) Photomicrograph (original magnification, x200; hematoxylin-eosin stain) shows eosinophilic inclusions (arrows) within large nuclei.

View larger version (112K): [in a new window]   Figure 8.  Pneumonia due to varicella-zoster virus in a 30-year-old man with a fever and skin rash. Thin-section (1-mm collimation) CT scan obtained at the level of the bronchus intermedius shows multiple 1-2-mm-diameter nodules scattered throughout both lungs. (Courtesy of Dong Wook Sung, MD, Kyung Hee University Hospital, Seoul, Korea.)

View larger version (93K): [in a new window]   Figure 9a.  Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia. (a) Thin-section (1-mm collimation) CT scan obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules (arrows) in both lungs. (b) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows diffuse interstitial and intraalveolar fibroblastic proliferation (arrows) with some mononuclear cell infiltration (diffuse alveolar damage, organizing stage). (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows three large nuclei containing eosinophilic inclusion bodies (arrows) within hyperplastic pneumocytes. (d) Photomicrograph (original magnification, x400; immunohistochemical marker for cytomegalovirus) shows positive intranuclear inclusion bodies (arrows).

View larger version (207K): [in a new window]   Figure 9b.  Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia. (a) Thin-section (1-mm collimation) CT scan obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules (arrows) in both lungs. (b) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows diffuse interstitial and intraalveolar fibroblastic proliferation (arrows) with some mononuclear cell infiltration (diffuse alveolar damage, organizing stage). (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows three large nuclei containing eosinophilic inclusion bodies (arrows) within hyperplastic pneumocytes. (d) Photomicrograph (original magnification, x400; immunohistochemical marker for cytomegalovirus) shows positive intranuclear inclusion bodies (arrows).

View larger version (143K): [in a new window]   Figure 9c.  Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia. (a) Thin-section (1-mm collimation) CT scan obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules (arrows) in both lungs. (b) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows diffuse interstitial and intraalveolar fibroblastic proliferation (arrows) with some mononuclear cell infiltration (diffuse alveolar damage, organizing stage). (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows three large nuclei containing eosinophilic inclusion bodies (arrows) within hyperplastic pneumocytes. (d) Photomicrograph (original magnification, x400; immunohistochemical marker for cytomegalovirus) shows positive intranuclear inclusion bodies (arrows).

View larger version (144K): [in a new window]   Figure 9d.  Pneumonia due to cytomegalovirus in a 28-year-old man with acute myeloid leukemia. (a) Thin-section (1-mm collimation) CT scan obtained at the level of the bronchus intermedius shows multifocal patchy ground-glass attenuation and poorly defined centrilobular nodules (arrows) in both lungs. (b) Photomicrograph (original magnification, x40; hematoxylin-eosin stain) shows diffuse interstitial and intraalveolar fibroblastic proliferation (arrows) with some mononuclear cell infiltration (diffuse alveolar damage, organizing stage). (c) Photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows three large nuclei containing eosinophilic inclusion bodies (arrows) within hyperplastic pneumocytes. (d) Photomicrograph (original magnification, x400; immunohistochemical marker for cytomegalovirus) shows positive intranuclear inclusion bodies (arrows).

View larger version (119K): [in a new window]   Figure 10a.  Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation. (a) Chest radiograph obtained 4 weeks after liver transplantation shows patchy air-space consolidation in both lungs. An endotracheal intubation tube, a pigtail drainage catheter in the right pleural space, a chest tube in the left pleural space, and a central venous catheter are seen. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the right upper lobe bronchus 2 days before a shows multifocal patchy ground-glass attenuation in both lungs. Note the consolidation (white arrow) and the small, poorly defined nodules (black arrows). There are associated bilateral pleural effusions.

View larger version (141K): [in a new window]   Figure 10b.  Pneumonia due to cytomegalovirus in a 45-year-old man who underwent liver transplantation. (a) Chest radiograph obtained 4 weeks after liver transplantation shows patchy air-space consolidation in both lungs. An endotracheal intubation tube, a pigtail drainage catheter in the right pleural space, a chest tube in the left pleural space, and a central venous catheter are seen. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the right upper lobe bronchus 2 days before a shows multifocal patchy ground-glass attenuation in both lungs. Note the consolidation (white arrow) and the small, poorly defined nodules (black arrows). There are associated bilateral pleural effusions.

View larger version (156K): [in a new window]   Figure 11a.  Pneumonia due to Epstein-Barr virus in a 25-year-old man with a fever, chills, and palpable lymph nodes. (a) Chest radiograph shows ground-glass opacity and multiple small nodules in both lungs, especially in the middle and lower lung zones, along with small bilateral pleural effusions. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the left inferior pulmonary vein shows numerous small nodules (arrows) and diffuse ground-glass attenuation.

View larger version (141K): [in a new window]   Figure 11b.  Pneumonia due to Epstein-Barr virus in a 25-year-old man with a fever, chills, and palpable lymph nodes. (a) Chest radiograph shows ground-glass opacity and multiple small nodules in both lungs, especially in the middle and lower lung zones, along with small bilateral pleural effusions. (b) Thin-section (1-mm collimation) CT scan obtained at the level of the left inferior pulmonary vein shows numerous small nodules (arrows) and diffuse ground-glass attenuation.