More than 40 hantavirus species are known, and greater than 20 of these are considered pathogenic in humans. The predominant CT findings are unilateral or bilateral ground-glass opacities with or without associated focal or multifocal areas of consolidation. Figure 1: Histopathologic features of pulmonary CMV infection. Image from scanning low-power microscopy (hematoxylin-eosin stain; original magnification, ×20) shows nodular zones of necrosis, some of which are bronchiolocentric (arrows). In May 2015, a large outbreak of MERS coronavirus infection occurred in South Korea, with 186 identified patients and 38 deaths. In a cohort of 310 patients with viral or non-viral community-acquired pneumonia viral pneumonia was associated with: Rhinorrhea, multivariate (OR 3.52; 95% CI, 1.58-7.87) Higher lymphocyte fraction in the white blood cells, Radiographic findings in 20 patients with Hantavirus pulmonary syndrome correlated with clinical outcome, Hantavirus pulmonary syndrome: high-resolution CT findings in one patient, Radiology of severe acute respiratory syndrome (SARS): the emerging pathologic-radiologic correlates of an emerging disease, Severe acute respiratory syndrome (SARS) coronavirus, Centers for Disease Control and Prevention (CDC), Outbreak of severe acute respiratory syndrome—worldwide, 2003, Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study, Thin-section CT in patients with severe acute respiratory syndrome following hospital discharge: preliminary experience, Guidelines for laboratory diagnosis of SARS-CoV infection, Centers for Disease Control and Prevention Web site, Pulmonary pathology of severe acute respiratory syndrome in Toronto, Lung pathology of fatal severe acute respiratory syndrome, Severe acute respiratory syndrome: radiographic and CT findings, Thin-section CT of severe acute respiratory syndrome: evaluation of 73 patients exposed to or with the disease, Severe acute respiratory syndrome: temporal lung changes at thin-section CT in 30 patients, Radiologic pattern of disease in patients with severe acute respiratory syndrome: the Toronto experience, Respiratory adenoviral infections in children: a study of hospitalized cases in southern Taiwan in 2001–2002, Reconstitution of adenovirus-specific cell-mediated immunity in pediatric patients after hematopoietic stem cell transplantation, Adenovirus pneumonia in adults: radiographic and high-resolution CT findings in five patients, Unilateral hyperlucent lung: MacLeod versus Swyer-James, Post-infectious bronchiolitis obliterans: clinical, radiological and pulmonary function sequelae, Pediatric pulmonary disease: assessment with high-resolution ultrafast CT, Spectrum of manifestations of Swyer-James-MacLeod syndrome, Dynamic ultrafast high resolution CT findings in a case of Swyer-James syndrome, Swyer-James syndrome: CT findings in eight patients, Adenovirus infection in hematopoietic stem cell transplantation: effect of ganciclovir and impact on survival, Adenovirus pneumonia in lung transplant recipients, Adenoviral bronchopneumonia in an immunocompetent adult: computed tomography and pathologic correlations, Bronchiolitis obliterans in children: clinical presentation, therapy and long-term follow-up, Herpes simplex virus 1 pneumonia: conventional chest radiograph pattern, Herpes simplex virus pneumonia: clinical, virologic, and pathologic features in 20 patients, Herpes simplex virus type 2 pneumonia after bone marrow transplantation: high-resolution CT findings in 3 patients, Varicella-zoster virus pneumonia in adults: report of 14 cases and review of the literature, Varicella pneumonia in patients with HIV/AIDS, High-resolution CT findings of varicella-zoster pneumonia, CT findings of varicella pneumonia after lung transplantation, Cytomegalovirus pneumonia after bone marrow transplantation: high-resolution CT findings, Cytomegalovirus pneumonia in transplant patients: CT findings, Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings, 11th Annual Meeting of the IHMF (International Herpes Management Forum), Management of CMV infection and disease in transplant patients. Nodules, micronodules, and tree-in-bud opacities.—Nodules 1–10 mm in diameter may be seen in a number of lung infections. Adenovirus affects the terminal bronchioles and causes bronchiolitis, which may be accompanied by necrotizing bronchopneumonia. †In immunocompromised patients, the reduction of immunosuppressive drugs generally is recommended. 35, No. Pneumonia due to HSV in a 72-year-old woman with multiple myeloma. RSV is the etiologic agent in most patients, but other viruses (adenovirus, influenza, parainfluenza) and nonviral pathogens (mycoplasma, Chlamydia species) can cause a similar syndrome (22). 9, No. The bronchiolitis may be necrotizing and result in a necrotizing bronchopneumonia similar to that seen in severe herpes simplex infection (13) (Fig 2). CT of common community-acquired viral lower respiratory tract infections (LRTIs) is still in its infancy, with only a few previously published studies comprising approximately 250 cases [1–19].However, to our knowledge, direct comparisons of the imaging features of the different viral causes of LRTI have not been performed. influenza pneumonia. Further studies aimed at elucidating the imaging findings of newly identified viral pathogens, including human bocavirus and coronaviruses, could be of value for proper diagnosis and improvement of clinical outcomes. Unfortunately, the diagnosis of viral pneumonia still relies heavily on clinician suspicion in the proper setting, which is based on host risk factors, presentation, and exposures. 1, Chinese Journal of Academic Radiology, Vol. These techniques include culture to prove replication of complete viral particles, hybridization techniques performed with or without PCR to detect viral nucleic acids, immunohistochemistry to detect viral proteins, electron microscopy to demonstrate a fully assembled virus, and measurements of a specific host immune response to the virus in either serum or cells or tissue. Adenovirus is a double-stranded DNA virus with more than 50 identified serotypes that account for 5%–10% of all respiratory tract infections in children (11). Direct contact with infected blood also can cause infection (51). (a) Initial chest radiograph shows multifocal reticulonodular infiltrations (arrows) in both lungs. The first goal of this review is to indicate that there are imaging features that should raise the possibility of viral infections. Severe fever with thrombocytopenia syndrome must be differentiated from hemorrhagic fever with renal syndrome or leptospirosis (52). Pneumonia due to influenza A virus in a 38-year-old pregnant woman at the gestational age of 29 weeks and 5 days who presented with a cough and dyspnea. Whereas hypoattenuated areas contain few and small pulmonary vessels (arrows), hyperattenuated areas contain enlarged pulmonary vessels (arrowheads), reflecting the pulmonary blood flow distribution toward normal ventilated areas. An adenovirus infection occurs in 10.5% of patients undergoing hematopoietic stem cell transplantation; younger age, alternative donor grafts, and acute graft-versus-host disease are risk factors for infection (15). Entidad infrecuente de difícil diagnóstico y mal pronóstico en trasplantados pulmonares, Lymphomes : principes thérapeutiques et imagerie post-thérapeutique, Nodular Inflammatory Foci Are Sites of T Cell Priming and Control of Murine Cytomegalovirus Infection in the Neonatal Lung, Computed tomography findings in patients with H1N1 influenza A infection. Until recently, Bunyaviridae was the largest group of RNA viruses, but it was replaced by Hantaviridae and Phenuiviridae. Enterovirus 69 has been isolated from the throat secretions of infants with bronchiolitis and pneumonia (116). Despite the obvious advantages of these newer procedures, there may be potential limitations to DNA amplification technology in the diagnostic microbiology laboratory, as follows: (a) False-negative test results may occur because of the presence of substances in the specimen that inhibit nucleic acid extraction or amplification, (b) careful interpretation of results is necessary, (c) the procedure is technically complex, (d) equipment is expensive, and (e) there is a lack of standardization (30,31). (b, c) Axial chest CT images obtained on the same day at the lower trachea level (b) and the interlobar area level (c) show multiple irregular areas of nodular tree-in-bud opacity and patchy consolidations (arrows) along the bronchovascular bundles and mild bronchial wall thickening. Herpesviridae have the ability to remain latent in tissue after the acute infection has resolved and can be reactivated by internal and external triggers. Hantaviruses are transmitted by rodent vectors, while the others in Bunyaviridae are transmitted by arthropod vectors. In patients suspected of having viral pneumonia, imaging is performed to help detect disease, assess disease extent, perform follow-up assessment of response to treatment, and guide interventional diagnostic procedures (eg, bronchoscopy with bronchoalveolar lavage). The patient died despite intensive medical care. Figure 12d. (a, b) Initial axial chest CT images at the main bronchial level (a) and the interlobar area level (b) show multifocal ill-defined nodular GGO lesions (arrows) along the bronchovascular bundles and mild bronchial wall thickening (arrowheads). Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands. Bocavirus is a single-stranded DNA virus and a member of the family Parvoviridae, first isolated in 2005 from nasopharyngeal aspirate specimens from children (33). Japan Radiological Society (JRS) has started surveillance on diagnostic imaging of virus pneumonia in order to grasp the novel coronavirus clusters and the spread of the virus infection in Japan. 6, Clinics in Chest Medicine, Vol. The need of a standardized reporting scheme and language, in imaging of COVID-19 pneumonia, has been welcomed by major scientific societies. Adenovirus infection exhibits more severe and fatal conditions with acute respiratory distress syndrome in immunocompromised patients. Figure 8: Transverse thin-section CT scan at the level of the bronchus intermedius in a patient with influenza A virus shows ill-defined centrilobular nodules (arrows). Influenza.—Influenza viruses are single-stranded RNA viruses that belong to the family Orthomyxoviridae. Pseudocavitation, pneumatocoele formation, lymphadenopathy, and centrilobular nodules are often seen. Pneumonia due to RSV in a 58-year-old woman with acute myeloid leukemia who presented with fever. (a) Initial chest radiograph shows ill-defined diffuse reticular areas of increased opacity (arrows) in both lungs. 94, No. Severe fever with thrombocytopenia syndrome virus is a type of tick-borne Phlebovirus. 1, Indian Journal of Transplantation, Vol. Nevertheless, the findings of CMV infection in patients with AIDS seem to differ from those in patients without AIDS (171). Prolonged neutropenia is noted. Adenovirus appears as multifocal consolidation or ground-glass opacity (GGO), and GGO was more frequently noticed in patients with adenovirus pneumonia than in those with other viral infections or bacterial infections. CMV does not produce clinical disease in most people with an intact immune system. Pneumonia due to adenovirus in a 20-year-old man with fever, cough, and dyspnea. 1, 12 November 2020 | Radiology: Cardiothoracic Imaging, Vol. Clinical symptoms include dry cough and rapidly increasing dyspnea (57). 123, No. The patient died despite intensive medical care. The most common method is the demonstration of measles virus–specific IgM in a single serum sample, but a more than fourfold titer increase in paired serum samples is also formal proof of a recent measles virus infection. The CT score, mean density, and mass of lesions in patients with CT consolidation showed a more severe clinical course of viral pneumonia in those patients compared with patients with GGO . There are a number of indicators for identifying viral pathogens on the basis of imaging patterns, which are associated with the pathogenesis of viral infections. Table 2: Pathogenesis and CT Findings of Viral Pneumonia. Figure 9c. Coxsackievirus, echovirus, and enterovirus.—Coxsackievirus is a RNA virus, genus Enterovirus. The incidence of severe pneumonia does not differ among human rhinovirus A (18.6%), human rhinovirus B (21.4%), and human rhinovirus C (20.0%), and in-hospital mortality rates also do not differ significantly (81). Primary HSV infection occurs by means of close personal contact through saliva or cutaneous or oral vesicle fluid, which can cause gingivostomatitis in children and herpes labialis in adults. Photomicrograph (hematoxylin-eosin stain; original magnification, ×100) shows interstitial widening with formation of micronodules (arrows). Whereas mild pulmonary infection often occurs in healthy adults, severe pneumonia, with an often protracted and fatal course, may occur in immunocompromised and debilitated patients. Figure 20: Transverse thin-section CT scan at the level of the lower pulmonary veins in a patient with SARS infection shows a focal area of consolidation in the medial segment of the left lower lobe (arrows) and bilateral ground-glass opacities in the lower lobes (arrowheads). Although consolidation is also relatively commonly seen in patients without AIDS, it is not dense and does not result in masslike opacities (173). On June 11, 2009, the World Health Organization declared the first pandemic of the 21st century caused by swine-origin influenza virus A (H1N1) (87). 2020, European Journal of Radiology Open, Vol. 40, No. After the patient underwent an emergency cesarean delivery, intubation and extracorporeal membrane oxygenation were performed for acute respiratory distress syndrome. Information on COVID-19 for medical personnel in radiology department. Influenza virus types A and B account for most viral pneumonias in immunocompetent adults (5). (b) Frontal chest radiograph obtained 6 hours later demonstrates rapid progression to diffuse perihilar and lower lung consolidation, reflecting associated diffuse alveolar damage. Pneumonia due to influenza A virus in a 38-year-old pregnant woman at the gestational age of 29 weeks and 5 days who presented with a cough and dyspnea. Pneumonia due to HMPV in a 50-year-old woman who presented with fever, cough, and sputum. 2, 30 March 2020 | Radiology: Cardiothoracic Imaging, Vol. Infections are usually mild and restricted to the upper respiratory tract. An earlier incorrect version of this article appeared online. Adenoviral infections are more common from fall to spring. (a) Chest radiograph shows diffuse irregular patchy consolidation (arrows) and GGO in both lungs. *The main routes of transmission are listed first. 57, No. (e) Pneumonia due to rhinovirus shows multiple ill-defined patchy areas of GGO (arrows) with interlobular septal thickening (arrowheads) in both lungs. HPIV is a single-stranded RNA virus and a member of the family Paramyxoviridae. 3).Ground-glass opacities are observed in 88 % of the patients [].Those initial changes most likely correspond to pulmonary edema with hyaline … Multicentric areas of hemorrhage may appear centered on airways. Journal of Thoracic Imaging, Vol. After the patient underwent an emergency cesarean delivery, intubation and extracorporeal membrane oxygenation were performed for acute respiratory distress syndrome. Figure 12: Transverse thin-section CT scan through the upper lobes in a patient with influenza pneumonia shows extensive bilateral ground-glass opacities. Parainfluenza virus.—Parainfluenza viruses belong to the family Paramyxoviridae and are known to be a common cause of seasonal upper respiratory tract infection in adults and children (92). All patients with neutropenic fever and normal findings at chest radiography should undergo thin-section computed tomography to determine whether parenchyma abnormalities are present. Patients have an abrupt onset of symptoms, which include fever, myalgia, malaise, chills, anorexia, and headache. (a) Pneumonia due to varicella-zoster virus shows multifocal 1–10-mm well-defined or ill-defined nodular opacity (arrows) with a surrounding halo or patchy GGO (arrowheads) in both lungs. Children typically present with rhinorrhea, fever exceeding 100.4°F (>38°C), nonproductive cough, progressive dyspnea, hypoxemia, and bronchiolitis. Severe forms of measles include pneumonia, blindness, gastroenteritis, and encephalitis. Air trapping may be present because of associated bronchiolitis (Fig 11). Similarly, cytomegalovirus (CMV) exhibits acute interstitial pneumonia with diffuse alveolar edema with fibrinous exudate. The most common radiologic abnormalities are mediastinal lymphadenopathy, and, rarely, interstitial infiltrates and widespread GGO can be seen. In a patient with HSV pneumonia who underwent open lung biopsy, areas of GGO on CT images corresponded to pathologic diffuse alveolar damage (9). Hyaline membranes, interstitial edema, interstitial infiltrates of inflammatory cells, and bronchiolar injury with loss of cilia are other observed features (136,137). Ulcerative mucosal changes are also seen (arrow). (b, c) Thin-section (1-mm collimation) axial (b) and coronal (c) reconstructed (5-mm section thickness) chest CT images obtained on the same day show multiple ill-defined centrilobular nodules (arrows) or GGO (arrowheads) along the bronchovascular bundles and mild bronchial wall thickening in both lungs, especially in the right lung. (Image courtesy of T. Colby, MD, Mayo Clinic, Scottsdale, Ariz.). To compare the chest computed tomography (CT) findings of coronavirus disease 2019 (COVID-19) to other non-COVID viral pneumonia. (b, c) Thin-section (1-mm collimation) axial CT image (b) and coronal reconstructed CT image (5-mm thickness) (c) obtained on the same day show multifocal ill-defined small areas of nodular opacity (arrows) with the GGO halo sign in both lungs. (d) Pneumonia due to influenza A virus shows multiple irregular areas of consolidation (arrows) along the bronchovascular bundles and diffuse GGO (arrowheads) with interlobular septal thickening in both lungs. Studies were eligible if they included immunocompetent patients with up to 14 days of viral pneumonia. (a) Pneumonia due to varicella-zoster virus shows multifocal 1–10-mm well-defined or ill-defined nodular opacity (arrows) with a surrounding halo or patchy GGO (arrowheads) in both lungs. (b, c) Axial thin-section (1-mm collimation) chest CT images obtained on the same day show irregular patchy consolidation (arrows) along the bronchovascular bundles and in peripheral areas of the lungs, bronchial wall thickening, and interlobular septal thickening (arrowhead), with a small amount of bilateral pleural effusion (*). Various histopathologic patterns of lung injury have been described in viral pneumonia. Before the development of the measles vaccine, many people with measles presented with fever, maculopapular skin rash, cough, coryza, or conjunctivitis. Acute bronchiolitis in adults may also be seen with aspiration, toxic inhalation, connective tissue diseases, lung and bone marrow transplantation, and Stevens-Johnson syndrome (23). Ribavirin is multipotent for the treatment of RSV, adenovirus, HPIV, and HMPV. There are bilateral well-demarcated patchy areas of increased and decreased lung attenuation. Figure 2: Histopathologic features of respiratory syncytial virus (RSV) bronchiolitis in a child. Figure 11c. CT patterns of viral pneumonia are related to the pathogenesis of viral infections. [10] Xu X. , et al., Evolution of the novel corona virus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission, Science China Life Sciences 63(3) (2020), 457–460. 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