Abstract
In patients presenting with classical features of CAP (i.e., new peripheral pulmonary consolidations and symptoms including fever, cough, and dyspnea), a clinical response to the appropriate therapy occurs in few days. When clinical improvement has not occurred and chest imaging findings are unchanged or worse, a more aggressive approach is needed in order to exclude other non-infective lesions (including neoplasms). International guidelines do not currently recommend the use of transthoracic ultrasound (TUS) as an alternative to chest X-ray (CXR) or chest computed tomography (CT) scan for the diagnosis of CAP. However, a fundamental role for TUS has been established as a guide for percutaneous needle biopsy (US-PNB) in pleural and subpleural lesions. In this retrospective study, we included 36 consecutive patients whose final diagnosis, made by a US-guided percutaneous needle biopsy (US-PTNB), was infectious organizing pneumonia (OP). Infective etiology was confirmed by additional information from microbiological and cultural studies or with a clinical follow-up of 6–12 months after a second-line antibiotic therapy plus corticosteroids. All patients have been subjected to a chest CT and a systematic TUS examination before biopsy. This gave us the opportunity to explore TUS performance in assessing CT findings of infective OP. TUS sensitivity and specificity in detecting air bronchogram and necrotic areas were far lower than those of CT scan. Conversely, TUS showed superiority in the detection of pleural effusion. Although ultrasound findings did not allow the characterization of chronic subpleural lesions, TUS confirmed to be a valid diagnostic aid for guiding percutaneous needle biopsy of subpleural consolidations.
Highlights
MATERIALS AND METHODSPatients presenting to the Emergency Department (ED) with respiratory symptoms, such as cough, purulent sputum, and dyspnea, may show pulmonary consolidations on standard chest x-ray (CXR)
The consolidation that was most clearly viewable on transthoracic ultrasound (TUS) examination was selected as target for systematic TUS study and subsequent US-guided percutaneous needle biopsy (US-PTNB) (Table 1)
We did not find a statistically significant difference between the mean diameter of the lesions measured on chest computed tomography (CT) scan and that measured on TUS examination, lesions appeared slightly smaller on TUS (4.15 ± 0.93 vs. 3.92 ± 0.88, p = 0.3)
Summary
Patients presenting to the Emergency Department (ED) with respiratory symptoms, such as cough, purulent sputum, and dyspnea, may show pulmonary consolidations on standard chest x-ray (CXR). The most common cause for new-onset pulmonary consolidations is an infective pneumonia [1, 2]. In a patient with chronic symptoms, persistent consolidations, not reducing in size or even worsening on follow-up CXR, open the scenario for a completely different spectrum of differential diagnoses, including inadequately treated or atypical infections, lung abscess, organizing pneumonia (OP), malignancy, chronic eosinophilic pneumonia, sarcoidosis, or vasculitis [3, 4]. Organization is believed to be a consequence of a prolonged inflammatory reaction causing alveolar epithelial injury with cell necrosis, denudation of the basal laminae and intra-alveolar fibrinous exudate [9]
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