European Journal of Radiology 51 (2004) 102–113

Radiology of bacterial pneumonia
José Vilar∗ , Maria Luisa Domingo, Cristina Soto, Jonathan Cogollos
Radiology Department, Hospital Universitario Doctor Peset, Valencia, Spain Received 23 February 2004; received in revised form 26 February 2004; accepted 1 March 2004

Abstract Bacterial pneumonia is commonly encountered in clinical practice. Radiology plays a prominent role in the evaluation of pneumonia. Chest radiography is the most commonly used imaging tool in pneumonias due to its availability and excellent cost benefit ratio. CT should be used in unresolved cases or when complications of pneumonia are suspected. The main applications of radiology in pneumonia are oriented to detection, characterisation and follow-up, especially regarding complications. The classical classification of pneumonias into lobar and bronchial pneumonia has been abandoned for a more clinical classification. Thus, bacterial pneumonias are typified into three main groups: Community acquired pneumonia (CAD), Aspiration pneumonia and Nosocomial pneumonia (NP).The usual pattern of CAD is that of the previously called lobar pneumonia; an air-space consolidation limited to one lobe or segment. Nevertheless, the radiographic patterns of CAD may be variable and are often related to the causative agent. Aspiration pneumonia generally involves the lower lobes with bilateral multicentric opacities. Nosocomial Pneumonia (NP) occurs in hospitalised patients. The importance of NP is related to its high mortality and, thus, the need to obtain a prompt diagnosis. The role of imaging in NP is limited but decisive. The most valuable information is when the chest radiographs are negative and rule out pneumonia. The radiographic patterns of NP are very variable, most commonly showing diffuse multifocal involvement and pleural effusion. Imaging plays also an important role in the detection and evaluation of complications of bacterial pneumonias. In many of these cases, especially in hospitalised patients, chest CT must be obtained in order to better depict these associate findings. © 2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Pneumonia; Bacterial pneumonia; Pulmonary CT; Nosocomial pneumonia

1. Introduction Bacterial pneumonias account for a large percentage of all pneumonias. They have been classified into three main groups: lobar pneumonia, bronchopneumonia and acute interstitial pneumonia [1]. Lobar pneumonias are characterised by confluent areas of focal airspace disease, usually limited to one lobe or segment. Bronchopneumonia has a multifocal distribution with nodules that tend to join producing air-space consolidations affecting one or more lobes. Acute interstitial pneumonias are produced by involvement of the bronchial and bronchiolar wall, and of the pulmonary interstitium, and are most commonly caused by viral organisms and Mycoplasma pneumoniae. This classic morphologic classification is of limited usefulness because the radiographic pattern often cannot be used to predict the causative organism. The appearance of new infective organisms, the increasing age of the population and the wide use of antibiotics have changed the pat∗

terns of this disease [2]. This is why most authors prefer to classify pneumonias from the perspective of the mechanism of origin. Thus, we will refer to three main groups of pneumonias: community acquired pneumonia (CAP), nosocomial pneumonia (NP) and aspiration pneumonia. Streptococcus pneumoniae is the most common cause of CAP while Gram-negative bacteria and Staphylococcus aureus are more often responsible for hospital acquired pneumonia [2]. Aspiration pneumonias are usually produced by micro-organisms that colonize the oropharynx which include Gram-positive cocci, Gram-negative rods, and rarely, anaerobic bacteria. This article will review the most common and some unusual radiographic presentations of bacterial pneumonia in inmunocompetent patients.

2. Imaging pneumonia In patients with suspected pneumonia, imaging plays a major role in the detection, characterisation and follow-up of the disease.

Corresponding author. E-mail address: vilar jlu@gva.es (J. Vilar).

0720-048X/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrad.2004.03.010

/ European Journal of Radiology 51 (2004) 102–113 103 2. Although the chest radiograph is often regarded as the reference standard for the diagnosis of community-acquired pneumonia. Vilar et al. 1. Additional value of CT: CAP (a) chest radiograph: there is a paratracheal opacity in the right upper lobe. [4] but the use of CT is only Fig. showing some infiltrates not visualised in the chest radiographs (Fig. (b) CT of the same patient shows clearly the opacity due an air-space consolidation.J. Indeed pulmonary infections are the most common reason for obtaining an emergency chest film.1. Pneumonia may present with a wide spectrum of symptoms and often the initial clinical manifestations are clear. 1) and can assure the existence of cavitation or other complications. its reliability is limited by significant interobserver variability in radiographic interpretation [3]. . Other techniques like computed tomography (CT) can be useful. Detection The basic and most diffused imaging tool to diagnose pneumonia remains the chest radiograph.

2. Magnetic resonance imaging (MRI) can demonstrate pulmonary consolidations. It is highly influenced by the geographic area. The incidence of these organisms varies according to the different authors. S. imaging may be of great help in detecting the associated findings. alcoholics. 2. The most common bacterial agents responsible for CAP are S. Haemophilus influenzae (20%) and M. the most common agent producing CAP was S.104 J. The authors concluded that radiology alone was unable to distinguish bacterial from non-bacterial pneumonias. CT is recommended [8. pneumoniae Fig. The characterisation of some NP may be quite difficult. while another publication [2] reported S.9]. In these cases. Thus. complications of pneumonia or suspicion of an underlying additional lesion such as bronchogenic carcinoma. pneumoniae (48%) followed by virus (19%). 2. C. The diagnostic accuracy was 67% for bacterial pneumonia and 65% for non-bacterial pneumonia. if the pneumonia does not resolve. pneumoniae. In a review of 114 cases of pneumonia. [3] showed that the chest radiograph reliability for detecting pleural fluid and multiple infiltrates was good. especially bronchogenic carcinoma. This is important since both findings are related to a worse prognosis.2. CAP may be caused by Gram-negative organisms in elderly patients. Community acquired pneumonia (Streptococcus pneumoniae) (a) and (b): PA and lateral chest films show consolidation in the lateral segment of the middle lobe. Otherwise. Reittner et al. pneumoniae (13%). the population studied and the diagnostic methods used [10]. alcoholism. diabetes and immune-deficiency.3. pneumoniae. [5] reviewed 31 patients with bacterial and non-bacterial pneumonias. in a study by Lim et al. It can be used as an alternative to CT in patients who should not be exposed to ionising radiation. A study by Albaum et al. especially in patients with assisted ventilation when other pulmonary conditions may coincide [7]. Despite these limitations. concluded that CT is also unable to differentiate the aetiology of various types of pneumonia except Pneumocystis carinii [6]. patients with cardiopulmonary disease and due to the widespread use of broad-spectrum antibiotics [1]. aureus may complicate a viral pneumonia. 3. / European Journal of Radiology 51 (2004) 102–113 recommended in cases uncertain to the chest film. Follow-up Most pnemonias will resolve in 1 or 2 weeks. abutting the major and minor fissures. pneumoniae (3%). M. [11]. Chlamydia pneumoniae and Legionella pneumophila. Community acquired pneumonia (CAP) The aetiology of CAP varies widely according to the different reviews published. Slow resolution can occur when there are certain associated conditions such as chronic obstructive pulmonary disease. an underlying pathology should be suspected. Vilar et al. Characterisation Is imaging reliable for distinguishing the infective organism? Tew et al. as mentioned previously. .

pneumoniae (13–37%) and C. CT may additionally show ground glass attenuation. M. Kantor [12] found Fig.11]. pneumoniae (17%) as most common agents. centrilobular nodules. limited by the pleural surfaces (Fig. 4. 3. 3. the use of antibiotics has changed the appearance of Pneumoccoccal pneumonia. 2). bronchial wall thickening and centrilobular branching structures [4] (Fig.1. and it may appear as patchy confluent areas that may be multilobar or bilateral (Fig. Mycoplasma pneumonia: chest radiograph. (9–20%). There is a diffuse peripheral and bilateral interstitial involvement. The usual imaging finding in CAP coincides with the classic presentation of lobar pneumonia: an airspace consolidation in one segment or lobe. The usual presentation is a lobar pneumonia involving one segment or lobe. Vilar et al. / European Journal of Radiology 51 (2004) 102–113 105 Fig.J. Pneumococcal pneumonia S. pneumoniae is the most frequent micro-organism causing CAP [2. PA chest radiograph shows an alveolar consolidation involving the right and left lower lobes in a patient infected by Streptococcus pneumoniae. Nowadays. 3). . 1b).

Vilar et al. / European Journal of Radiology 51 (2004) 102–113 Fig. notice the rapid extension of the consolidation. the consolidations are multiple and bilateral. 5. (a) Legionella pneumonia: chest radiograph of a patient with fever. (b) Chest radiograph obtained 48 h later. . dyspnea and myalgias. There is a smooth bilateral perihilar consolidation.106 J. (c) and (d) On CT.

5. Vilar et al. / European Journal of Radiology 51 (2004) 102–113 107 Fig. (Continued ). .J.

aspiration pneumonia occurs [20]. the incidence may reach up to 50%. a rapid growth is observed or there are signs of infection [18]. pneumoniae is similar to that of M. most frequently in places where the population is exposed to air conditioning towers. particularly in the right lung. Bilateral or multilobar pneumonia CAP can be diffuse and bilateral in patients with underlying chronic obstructive pulmonary disease due to the distortion and destruction of the pulmonary parenchyma (Fig.2. 8). Round pneumonia: a consolidation is seen in the right lower lobe lung of this adult patient. 7). seizures. and if it is of colonised oropharingeal material. A variant of this could be the cases described in screening for lung cancer where some small pulmonary nodules detected will disappear after the antibiotic treatment [19]. with a perihilar and basal distribution (Fig. Chlamydia pneumonia The radiographic appearance of C. dyspnea and cough. water distribution systems and humidifiers colonised by the germ [16]. excluding any infection that is incubating at the time of hospital admission. The radiographic appearance of aspiration pneumonia and pneumonitis is variable [21] but the most common pattern is that of bilateral and multicentric opacities. Aspiration pneumonia is conditioned by neurologic disphagia.5.2. Aspiration is the inhalation of orofaringeal or gastric contents into the larynx and lower respiratory tract. These infections are acquired by breathing droplets of contaminated water. Nosocomial pneumonias Nosocomial pneumonia or hospital acquired pneumonia is defined as a pneumonia occurring 48 h after hospital admission. Mycoplasma pneumonia has variable radiographic appearances. The radiographic findings are often those of segmental peripheral consolidations that spread rapidly producing opacification of one or more lobes (Fig. consisting in diarrhoea. Aspiration pneumonia 5. A review of 31 cases of M. Every 4–8 years. 3. gastroesophageal reflux in elderly persons. 3. round pneumonia should be suspected especially if no previous films are available. most commonly as a localised area of consolidation which may be patchy or homogeneous.3.5. 6. Some of these cases will present as a linear pattern that could be confused with other aetiologies. 4. pneumoniae. The disease may be sporadic or may occur in outbreaks. or the use of anaesthesia. Unusual patterns of CAP 3. 3. while the other with a longer duration of symptoms. anatomic abnormalities of the upper aerodigestive tract. 3. massive cerebrovascular accident. Chlamydia and Mycoplasma often coexist [1].1. . 5). They become bilateral in half of the cases [17]. Putnan et al. Mycoplasma pneumonia The incidence of Mycoplasma infection is variable according to different series and may be influenced by epidemics. Fig. If the inhalation is of regurgitated sterile gastric contents. headache. Round pneumonia (Fig. had a diffuse bilateral reticulo-nodular pattern (Fig.4. and also a pneumonia which occurs within 48 h after discharge from the hospital [22]. 3. / European Journal of Radiology 51 (2004) 102–113 that the patterns of lobar pneumonia and bronchopneumonia were equally frequent in Pneumococcal pneumonia. In 1975. 6) It was described in children but occasionally it may happen in adults.5. myalgias.108 J. [14] identified two main clinical and radiographic groups: one group had unilateral or bilateral air-space disease with a lobar or segmental distribution. or poor oral care. This is a pneumonia of children. Streptococcus pneumoniae was obtained in the sputum cultures. Factors that predispose to aspiration pneumonitis are those that produce disturbance of consciousness such as drug abuse. Vilar et al. Legionella pneumonia Legionnella pneumophila is responsible for Legionnella pneumonia or Legionnaires’ disease. aspiration pneumonitis is caused. adolescents and adults below 40 years of age [13]. The clinical features of Legionella pneumonia are typical. pneumoniae in outpatients revealed no predominant radiographic pattern (interstitial or alveolar) with more frequent involvement of the lung bases [15]. Another common finding in Pneumococcal pneumonia is the presence of small pleural effusions that are usually reactive. 4). In the presence of a pulmonary nodule.

severity of the underlying disease. According to the literature. the length of hospitalisation and the instrumentation used in invasive techniques. coli. (a) Chest radiograph of a patient with bullous emphysema. Bilateral lower lobe consolidations. multiple different germs are found [23]. probably because the groups of patients studied differ and the diagnostic criteria vary. Fig. Quite often. and some Gram-positive cocci such as S. age. these pneumonias are more frequent. aureus and S. Anaerobic organisms are less common. E. (b) The same patient with pneumonia in the left upper lobe. the incidence of NP is variable. (c) CT of this area showing the fluid filled bulla. and the mortality is very high (10–50%). Risk factors involved in NP are the previous condition of the patient. Aspiration pneumonia: chest radiograph of a patient in a comatose condition due to drug abuse. pneumoniae. / European Journal of Radiology 51 (2004) 102–113 109 Fig. These variations depend greatly on the type of hospitalisation and wards (surgical or medical). Pseudomona aeruginosa).J. Vilar et al. 8. In patients hospitalised in Intensive Care Units. The most common micro-organisms responsible for NP are aerobic Gram-negative bacilli (Enterobacteriae. An air–fluid level (arrows) within the bullae mimics cavitation. 7. Mechanical ventilation constitutes a great risk factor for NP since it can facilitate the growth and .

NP in the Intensive Care Units may also occur in non-ventilated patients. . pneumoniae. Thus NP has been classified in two groups: ventilator associated pneumonia and pneumonia in non-ventilated patients [24]. and they also differ in their treatment. This has been denominated as ventilator associated pneumonia (VAP). Nevertheless. / European Journal of Radiology 51 (2004) 102–113 Fig. Nosocomial pneumonia: chest radiograph shows patchy and peripheral areas of consolidation in a hospitalised non-ventilated patient under a long-term treatment with steroids. Acinetobacter was obtained from bronchoaspirate cultures. dissemination of germs and the cough mechanism is reduced. The responsible organism was Pseudomona aeruginosa. while VAP occurring after 5 days (Fig. Ventilator assisted pneumonia: chest radiograph of a patient obtained after 5 days of mechanical ventilation. 10.110 J. Micro-organisms responsible for VAP vary according to the duration of mechanical ventilation: VAP occurring in the first 5 days of ventilation is usually due to S. influenzae or Moxarella catarrhalis and uncommonly by anaerobes. 9) of ventilation is most commonly Fig. The incidence and mortality of the former is much higher than that of NP in non-ventilated patients. H. Vilar et al. 9. There is a right perihilar consolidation.

especially after vigorous physiotherapy. Fig. and often caused by atelectasis. In summary. 6. the agreement between readers in this pathology is very low. In patients with ARDS.28]. Vilar et al. (a) Chest radiograph of a 12 months old child. oedema or acute respiratory distress syndrome (ARDS). Delay in treating pneumonia may be fatal and treating with antibiotics other entities (pulmonary infarction. Additionally. since the presence of focal alveolar consolidations is quite frequent in these patients. Complications All pneumonias. CT may be of great help in some cases when the chest films are inconclusive especially in patients with ARDS. except in patients with ARDS [26]. In hospitalized patients. A cystic space has developed in the area of previous pneumonia. Fig. The radiographic signs of NP are non-specific. found that the only reliable sign of pneumonia was the presence of air bronchograms. They may frequently associate pleural effusion (Fig. Complications are more common in inmunodepressed patients and in nosocomial pneumonias.J. 10). 11. The radiographic pattern of NP may be quite variable These pneumonias are most commonly bilateral with diffuse or multiple foci of consolidation not limited to one lobe [7]. the chest radiographs are most helpful when they are normal and rule out pneumonia [7]. symmetric and more evident in dependent areas [29]. pulmonary infarction. with a consolidation in left lower lobe. / European Journal of Radiology 51 (2004) 102–113 111 produced by Pseudomonas aeruginosa. or methicillin-resistant S. The role of portable chest films in cases of suspected NP is limited. CAP and nosocomial may complicate. Hospital acquired pneumonia: pulmonary gangrene produced by Klebsiella pneumoniae in a hospitalised patient. the diagnosis of pneumonia becomes very difficult [27. the role of radiology in NP is limited but decisive. 12. (b) Chest radiograph obtained 4 weeks later. Notice sloughed lung tissue due to extensive necrosis in a large cavity with an air–fluid level. ARDS is bilateral.. aureus [25]. A study by Wunderink et al.The presence of focal areas of consolidation favours the diagnosis of pneumonia but asymmetry may also occur in ARDS [29]. corresponding to a pneumatocele (arrows). Generally. and other factors such as the technique used to obtain the chest radiograph and the ventilator settings may influence the results [30]. . Acitenobacter or Enterobacter spp. Atelectasis may solve rapidly. oedema) may also have negative results.

13. 12). (b) Lateral chest radiograph showing posterior displacement of the major fissure due to abundant exudate by Klebsiella pneumoniae. 7. Thoracic radiology.163(7):1730–54. they become complicated and progress to empyema [31]. Kuramitsu T. Matsumoto T. USA. in 1949 and initially attributed to Klebsiella pneumonia (Friedlander’s pneumonia) [32]. The role of radiology in the intensive care unit patient is more limited since there is a great overlap of pathologies that can have similar radiographic signs. 1998. [2] American Thoracic Society. 6. / European Journal of Radiology 51 (2004) 102–113 Cavitation suggests bacterial disease rather than viral or Mycoplasma infection. High resolution CT findings in community-acquired pneumonia. S. 7). 11). In: McLoud TC. Pneumatocele [1] is an air cystic space that may develop as a complication of acute staphylococcal infection in children (Fig. pneumoniae and Klebsiella are the most common agents responsible for cavitation in inmunocompetent patients and Aspergillus in the inmunocompromised host (Fig. The chest radiograph remains a basic tool for this purpose. J Comput Assist Tomogr 1996. Loefflers pneumonia: (a) the chest radiograph shows an opacity in the left upper lobe. et al. Care needs to be taken to avoid misdiagnosing cavitation and pneumatocele formation when the focal lucencies within the consolidation are due to underlying emphysema (Fig. Gram-negative. Vilar et al. anaerobic bacteria are the most common agents. nosocomial pneumonia and aspiration pneumonia. Am J Respir Crit Care Med 2001. McLoud TC. the requisites. Guidelines for the management of adults with community-acquired pneumonia. Hill LC. Close follow-up of these patients and adequate clinical correlation is mandatory. Pleural effusion and empyema Parapneumonic effusions complicate the course of 20–60% of patients hospitalised with bacterial pneumonia. editor.20:600–8. Swellling of a lobe occurs when there is an extensive exudative process. . Interobserver reliability of chest radiograph in community-acquired pneumonia.1.110:343. The role of the radiologist is to be decisive in their diagnosis and follow-up.2. Most of these effusions follow an uncomplicated course and resolve with antibiotic therapy of the underlying pneumonia. Lobar enlargement This sign was well described by Felson et al. Pleural effusion in CAP is less frequent and usually reactive. Chest 1996. Fig. 13). Other infectious processes such as tuberculosis and pneumococci can also demonstrate lobar enlargement (Fig. CT in these cases can add significant information when portable films are inconclusive. [3] Albaum MN. References [1] Bhalla M. Pulmonary infections in the normal host.112 J. Mosby. Conclusions Pneumonias can be classified in three main groups: community acquired pneumonia. [4] Tanaka N. aureus. In 5–10% cases. Pulmonary gangrene is a rare but interesting form of cavitation that produces sloughed lung within a large cavity secondary to thrombosis of the pulmonary vessels [17]. 6. Murphy M. S. CT is used as a complement to plain films and especially in the evaluation of complications or unfavourable resolution of a pulmonary infiltrate.

[7] Chastre J. Chest 1978. [13] Ghosh K. et al. Dee P. ECR 2001—Presentation B-0937. [8] Johnson JL. [9] Burke M. Radiology 1998. In: Armstrong P. [16] Roig J. Revisión de las diferentes normativas sobre el tratamiento de la neumon´ ıa adquirida en la comunidad. 1445–59. [11] Lim WS. AJR 1998. editors. Vilar et al. The radiologic diagnosis of autopsy-proven ventilator associated pneumonia. Torres A. Radiology 1975. Radiology of pneumonia. Curtis AM. Mulle NL. p. Ventilator-associated pneumonia. [32] Felson B. Berlin B. Szabunio M.54:1036–40. Wells AU. Bacterial or nonbacterial pneumonia: accuracy of radiographic diagnosis. Hansell D. Steiner RM. Roentgen findings in acute Friedlander’s pneumonia. Rubens MB. Wagner SG. Infections of the lungs and pleura. Postgrad Med 2000. Yakelevich D.165(7):867–903. 1995.20(3):549–62.137:1213. Mycoplasma pneumoniae: clinical and roentgenographic patterns.J. Clin Chest Med.25(2):221–7.344(9):665–71. Sabria M.117:188s–90s. editor. Hamburger M. Slowly resolving and nonresolving pneumonia: questions to ask when response is delayed.108(6):115– 22.208:193–9. [17] Armstrong P. [25] Grossman RF.53:559. Hazlett KS.55(2):108–12.56:296–301. Calenoff L. Dee P. Radiologic manifestations of round pneumonia in adults. Lacher DA. / European Journal of Radiology 51 (2004) 102–113 [5] Tew J. Naidich D. Potts DE. Rubio C. Gurney JW. Pedro-Botet ML. Zeiss J.: community acquired and nosocomial infections. editors. [24] Ewing S. [30] Wunderink RG. [12] Kantror HG. Chest 2002. Ventilatorassociated pneumonia in patients with adult respiratory distress syndrome: CT evaluation. Curr Opin Infect Dis 2003. AJR 1981.170:723–6. Radiology 1988. In: Ginestal RJ. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary injury: a comparative CT study. Wilson A. 2nd ed. St. J Infect 1992. Chest 2000. et al. Sahn SA. Heyneman L. p. [21] Katz DS. Study of community acquired pneumonia aetiology in adults admitted to hospital: implications for management guidelines. Suntharalingam G. Boswell TCJ. Thorax 1999. Louis. Surveillance of Mycoplasma pneumoniae infections in Scotland 1986–1991. Goldenberg LS. Torres A. Evidence-based assessment of diagnostic tests for ventilation-associated pneumonia.101:458–63. Day CM.117:177–81. . [23] Marav´ ı-Poma E.124:417. [28] Bauer TT. Am J Respir Crit Care Med 2002. [10] Torres A. Manrique A. Fraser R. Chest 1992. Ciemins J. Clements GB. et al.122(6):2183–96. et al. [20] Marik PE. [14] Putnam CE. Cancer 2001. The many radiologic faces of pneumococcal pneumonia.2:80–6. Evans TW.166:699. [27] Winer-Muram HT. et al. 145–228. [26] Wunderink RG. 1991. Early lung cancer action project.92(1):153– 9. Cuidados intensivos. Radiology 1977. The pulmonary physician in critical care. Madrid: ELA. Pneumonia due to mycoplasma pneumonia in a primary health care district. Radiologic diagnosis of ventilator-associated pneumonia. The incidence and clinical correlates of parapneumonic effusions in pneumococcal pneumonia. Macfarlane JT. Rosemberg LS. Fein A. Pneumonia: highresolution CT findings in 114 patients.74:170. Simeone JF. Chest 2000.57:366–71. Maldonado MJ. [6] Reittner P. Imaging of diseases of the chest. Soler N. 1999. Obstructive pneumonitis: a pathologic and pathogenic reapraisal. Initial findings on repeat screening. 113 [19] Henschke C. Bauer T. Hansell DM. Thorax 2001. Nosocomial pneumonia.124:607–12. [15] Sánchez J. Legionella spp. Acute respiratory dystress syndrome and nosocomial pneumonia. Aspiration pneumonitis and aspiration pneumonia. Med Clin Monogr 2001. [29] Desai SR.16(2):145–51. Fagon JY.218:689–93. et al. Niederman MS. Radiology 1949. [22] Höffken G. Infecciones respiratorias nosocomiales. In: Niederman MS. Thorax 2002. Leung AN. An Esp Pediatr 2001. Ward S. [31] Taryle DA. Radiology 2001. N Engl J Med 2001. [18] Wagner AL.

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