Consolidation



Consolidation


Daniel J. Podberesky, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Infectious Pneumonia


  • Aspiration Pneumonia


  • Pulmonary Edema


  • Atelectasis


Less Common



  • Pulmonary Contusion


  • Pulmonary Hemorrhage


  • Pulmonary Infarct


  • Lymphoma


Rare but Important



  • Radiation Pneumonitis


  • Hydrocarbon Aspiration


  • Hypersensitivity Pneumonitis


  • Pulmonary Alveolar Proteinosis


  • Bronchiolitis Obliterans with Organizing Pneumonia


  • Lymphoid Hyperplasia


  • Near-Drowning


  • Pulmonary Inflammatory Pseudotumor


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Blood, pus, protein, water, cells


  • History extremely helpful


Helpful Clues for Common Diagnoses



  • Infectious Pneumonia



    • Lung consolidation ± air bronchograms


    • Not associated with volume loss


    • ± associated parapneumonic effusion


    • Round pneumonia



      • Young children


      • Poorly developed collateral airway pathways


  • Aspiration Pneumonia



    • Typically oral or gastric contents


    • Chemical pneumonitis, which can be superinfected


    • When upright, right lower lobe most frequent


    • When supine, posterior segments of upper lobes and superior segments of lower lobes most frequent


  • Pulmonary Edema



    • Transudative fluid collecting in lung tissue


    • May result from



      • Increased hydrostatic gradient


      • Low oncotic pressure


      • Increased capillary permeability


    • Interstitial edema may progress to alveolar edema and consolidation


    • Pleural effusions


    • Cardiogenic vs. noncardiogenic (e.g., neurogenic, renal or hepatic disorders, toxins)


  • Atelectasis



    • Airspace collapse resulting in increased lung density


    • Volume loss



      • Elevation of diaphragm


      • Cardiomediastinal shift


      • Shift of fissures


      • Crowding of vessels


    • Can be lobar, segmental, subsegmental, or plate-like


    • Frequently seen in inpatient settings, viral respiratory infections, and asthmatic patients


Helpful Clues for Less Common Diagnoses



  • Pulmonary Contusion



    • Edema and hemorrhage collecting in area of lung trauma


    • Typically evolve on radiography over 24-48 hours


    • Typically resolve in 3-5 days


    • Look for other signs of trauma



      • Pneumothorax, mediastinal injury, fractures, pleural fluid


  • Pulmonary Hemorrhage



    • Can be indistinguishable from other sources of consolidation on radiograph


    • May resolve fairly rapidly


    • Common causes in children include



      • Infection


      • Cystic fibrosis


      • Immunologic disorders (e.g., Goodpasture syndrome)


      • Wegener granulomatosis


      • Trauma


  • Pulmonary Infarct



    • Usually result of pulmonary embolus


    • Peripheral, wedge-shaped consolidation


    • Hampton hump: Pleural-based, peripheral, wedge-shaped consolidation secondary to pulmonary embolus


  • Lymphoma



    • Can present as chronic lung consolidation


    • Non-Hodgkin most frequent



    • Consider AIDS-related primary pulmonary lymphoma


    • Lymphadenopathy


Helpful Clues for Rare Diagnoses



  • Radiation Pneumonitis



    • Typically requires at least 4500 rads


    • Acute



      • 1-8 weeks after radiation


      • Patchy consolidation confined to radiation portal


    • Chronic



      • 9-12 months after radiation and beyond


      • Consolidation and fibrosis/scarring


      • Bronchiectasis


  • Hydrocarbon Aspiration



    • Gasoline, kerosene, lighter fluid


    • Severe chemical pneumonitis


    • Patchy consolidation develops over several hours


    • Edema


  • Hypersensitivity Pneumonitis



    • a.k.a. extrinsic allergic alveolitis


    • Type 3 immune response to environmental antigen



      • Moldy hay, dust, pigeon droppings


    • Reticulonodular opacities typically seen on x-ray


    • Consolidation may occur during acute/subacute phase


    • HRCT may demonstrate ground-glass opacities, centrilobular nodules, and consolidation


  • Pulmonary Alveolar Proteinosis



    • Accumulation of PAS-positive phospholipids in alveoli


    • Perihilar consolidation


    • “Crazy-paving” on CT



      • Ground-glass opacities and septal thickening


    • Diagnosis via bronchoalveolar lavage


  • Bronchiolitis Obliterans with Organizing Pneumonia



    • a.k.a. cryptogenic organizing pneumonia


    • Granulation tissue in bronchioles and alveolar inflammation


    • Patchy alveolar consolidation, ground-glass opacification, centrilobular nodules


    • Diagnosis via tissue biopsy


  • Lymphoid Hyperplasia



    • Nonneoplastic nodular proliferation


    • Nonspecific nodular areas of consolidation


    • Adenopathy


  • Near-Drowning



    • Drowning 2nd most common cause of accidental death in children


    • Hypoxemia secondary to aspiration or laryngospasm


    • Pulmonary edema pattern on x-ray that may have delayed appearance


    • Edema typically resolves fairly rapidly


  • Pulmonary Inflammatory Pseudotumor



    • a.k.a. plasma cell granuloma


    • Most common benign lung neoplasm in children


    • May involve mediastinum and pleura


    • Occasional calcifications






Image Gallery









Frontal radiograph shows focal consolidation image within the superior segment of the left lower lobe without associated volume loss, consistent with pneumonia in this toddler with a cough and fever.






Frontal radiograph shows 2 areas of consolidation in the right lower lobe image. The more lateral density image is consistent with a round pneumonia in this 6 year old with a cough and fever.

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Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Consolidation

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