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Cardiopulmonary Imaging Review

Walker et al.
Imaging Pulmonar y Infection

Cardiopulmonar y Imaging


Imaging Pulmonary Infection:

Classic Signs and Patterns
Christopher M. Walker 1 OBJECTIVE. The purposes of this article are to describe common
Gerald F. Abbot t 1
and uncommon imag- ing signs and patterns of pulmonary infections
Reginald E. Greene1
Jo-Anne O. Shepard1 and to discuss their underlying anatomic and pathophysiologic basis.
Dharshan Vummidi2 CONCLUSION. Imaging plays an integral role in the diagnosis
Subba R. Digumarthy 1 and management of sus- pected pulmonary infections and may reveal
Walker CM, Abbott GF, Greene RE, Shepard useful signs on chest radiographs and CT scans. Detected early, these
JO, Vummidi D, Digumarthy SR signs can often be used to predict the causative agent and pathophysi-
ologic mechanism and possibly to optimize patient care.

ulmonary infections are among

Consolidation and Air
the most common infections Bronchogram Sign
encoun- tered in outpatient and Consolidation is an alveolar-filling process
inpatient clinical care. that replaces air within the affected airspac-
According to the
Centers for Disease Control and Prevention, associated with bac- terial, viral, fungal, and
in- fluenza and pneumonia were combined as parasitic infections.
the eighth leading cause of death in the
United States in 2011 [1]. Imaging studies are
critical for the diagnosis and management of
pulmo- nary infections. When the imaging
manifes- tations of a known disease entity
form a consis- tent pattern or characteristic
appearance, those manifestations may be
regarded as an imaging sign of that disease.
Imaging signs by them- selves are sometimes
Keywords: abscess, fungus, infection, signs nonspecific and may also be manifestations of
noninfectious diseases. Various imaging signs
of thoracic infection can be clinically useful,
Received June 26, 2013; accepted after revision sometimes suggesting a specific diagnosis
August 16, 2013. and often narrowing the dif- ferential
1 diagnosis. Clinical data, such as WBC count,
Department of Radiology, Thoracic Imaging Division,
Massachusetts General Hospital, 55 Fruit St, Boston,
results of microbiologic tests, and im- mune
MA 02114. Address correspondence to C. M. Walker status, should be correlated with the im- aging
(walk 006 0 @ sign and any additional findings to facili- tate
an accurate diagnosis. The objectives of this
Department of Radiology, University of Michigan,
article are to discuss common and uncom-
Ann Arbor, MI.
mon signs and findings of pulmonary
This article is available for credit. infection at radiography and CT, discuss the
mechanisms and pathophysiologic factors that
AJR 2014; 202:479 492
produce those findings, and highlight several
0361 803X /14/2023 479 noninfectious diseases that may present with
similar findings. This review is divided
American Roentgen Ray Society into signs that are most commonly seen or

47 AJR:202, March 2014 AJR:202, March 2014 47

9 9
es, increasing in pulmonary attenuation air bronchogram sign (Fig. 1), initially include nonobstructive atelectasis, aspiration,
and obscuring the margins of adjacent described by Felix Fleischner in 1948 [3, 4]. and neoplasms, such as adenocarcinoma and
airways and vessels on radiographs and In normal lung, air-filled bron- chi are not lymphoma. One can dif- ferentiate atelectasis
CT scans [2]. Consolidation is one of the apparent on chest radiographs be- cause from pneumonia by look- ing for direct and
more common manifestations of they are surrounded by aerated lung pa- indirect signs of volume loss, including
pulmonary infection, and its appearance renchyma. In a patient with fever and bronchovascular crowding, fissural
is variable, dependent on the causative cough, this sign suggests the diagnosis of displacement, mediastinal shift, and diaphrag-
organism. pneumonia. Though the sign is most matic elevation. Detection of the air broncho-
Air-filled bronchi may become visible commonly seen with bacterial infection, any gram sign argues against the presence of a
when surrounded by dense, consolidated infection can manifest the air bronchogram cen- tral obstructing lesion.
lung paren- chyma and may produce the sign. Differential diag- nostic considerations

48 AJR:202, March 2014 AJR:202, March 2014 48

0 0
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Imaging et al. Infection

Silhouette Sign (e.g., cystic fibrosis or immune deficiency), come to be recognized as a potential mani-
The silhouette sign was initially diffuse panbronchiolitis, and adenocarcino- festation of other conditions, including me-
described by Felson as a radiographic sign ma [11]. Aspiration generally results in de- tastasis, arteriovenous fistula, and pulmonary
that enabled the anatomic localization of pendent tree-in-bud opacities predominat- vasculitis [23]. Septic emboli should be con-
abnormalities on orthogonal chest ing in the lower lung zones. Cystic fibrosis sidered when the feeding vessel sign is seen
radiographs [5]. The silhouette sign should be considered when upper-lung- with cavitating and noncavitating nodules
describes loss of a normal lungsoft-tissue zone predominant bronchiectasis, bronchial and subpleural wedge-shaped consolidation.
interface (loss of silhouette) caused by any wall thickening, mucus plugging, and mosaic The nodules usually have basal and peripher-
pathologic mechanism that re- places or at- tenuation are seen in combination with al predominance and vary in size [24]. Arte-
displaces air within the lung pa- renchyma. tree- in-bud opacities. Diffuse riovenous fistula is differentiated from septic
The silhouette sign is produced on chest panbronchiolitis should be considered when emboli by the finding not only of a feeding
radiographs when the loss of inter- face diffuse and uni- form tree-in-bud opacities artery but also of an enlarged draining vein.
occurs between structures in the same are seen in a pa- tient of East Asian descent.
anatomic plane within an image. This sign Less commonly, the tree-in-bud sign may be Inhomogeneous Enhancement
is commonly applied to the interface a manifestation of vascular lesions (so-called Sign and Cavitation
between the lungs and the heart, vascular tree- in-bud), including embolized In a patient with pneumonia, the CT de-
mediastinum, chest wall, and diaphragm. tumor or for- eign material, due to the tection of inhomogeneous enhancement and
Consolidation that ex- tends to the border of anatomic location of small arterioles as cavitation suggests the presence of necro-
an adjacent soft-tissue structure will paired homologous struc- tures that course tizing infection [25, 26]. Pulmonary necro-
obliterate its interface with that structure alongside the small airways in the sis may become evident as hypoenhancing
[5]. For example, lingular pneumo- nia centrilobular aspect of the secondary geographic areas of low lung attenuation
obscures the left-heart border, and mid- dle pulmonary lobules [8, 1215] (Fig. 4). that may be difficult to differentiate from ad-
lobe pneumonia obscures the right-heart jacent pleural fluid [25] (Fig. 7). This find-
border, because the areas of consolidation Bulging Fissure Sign ing is often seen before frank abscess forma-
and the respective heart borders are in the The bulging fissure sign represents tion and is a predictor of a prolonged hospital
same anatomic plane (Fig. 2). Conversely, expan- sive lobar consolidation causing course [26]. A cavity is defined as abnormal
with lower lobe pneumonia, the heart bor- fissural bulging or displacement by copious lucency within an area of consolidation with
der is preserved, but the ipsilateral hemidia- amounts of inflammatory exudate within or without an associated air-fluid level. Cav-
phragm is frequently obscured (silhouetted). the affected parenchyma. Classically itation may be the result of suppurative or
It is important to consider a diagnosis of associated with right upper lobe caseous necrosis or lung infarction. Impor-
bac- terial pneumonia in a patient with fever consolidation due to Klebsiella pneumoniae tantly, cavitation does not always indicate
and cough when the silhouette sign is (Fig. 5), any form of pneumonia can a lung infection or abscess. Cavitation can
detected at chest radiography. Other manifest the bulging fissure sign. The sign have noninfectious causes, including malig-
diseases that can manifest the silhouette is frequently seen in patients with pneu- nancy, radiation therapy, and lung infarction
sign include atelecta- sis (segmental or mococcal pneumonia [16, 17]. The [2]. Suppurative necrosis usually occurs with
lobar), aspiration, pleural effusion, and prevalence of this sign is decreasing, likely infection by Staphylococcus aureus, gram-
tumor [5]. because of prompt administration of negative bacteria, or anaerobes. Caseous ne-
antibiotic therapy to patients with suspected crosis is a characteristic histologic feature of
Tree-in-Bud Sign pneumonia [18]. The bulging fissure sign is mycobacterial infection, but cavitation is a
The small airways or terminal bronchioles also less com- monly detected in patients common pathologic and imaging feature of
are invisible on CT images because of their with hospital-ac- quired Klebsiella angioinvasive fungal infections, such as as-
small size (< 2 mm) and thin walls (< 0.1 pneumonia than in those with community- pergillosis and mucormycosis.
mm). They may become indirectly visible on acquired Klebsiella infec- tion [19]. Other
CT images when filled with mucus, pus, flu- diseases that manifest a bulging fissure Air-Fluid Level Sign
id, or cells, forming impactions that resemble include any space-occupying process in the In a patient with pneumonia, detection of
a budding tree with branching nodular V- lung, such as pulmonary hem- orrhage, lung an air-fluid level on chest radiographs or CT
and Y-shaped opacities that are referred to abscess, and tumor. images suggests the presence of a lung ab-
as the tree-in-bud sign [69] (Fig. 3). scess or empyema with bronchopleural fis-
Because tree- in-bud opacities form in the Feeding Vessel Sign tula. The former typically requires medi-
center of the sec- ondary pulmonary lobule, The feeding vessel sign is the CT find- cal treatment with antibiotics, and the latter
they characteristi- cally spare the subpleural ing of a pulmonary vessel coursing to a dis- usually requires insertion of a chest tube for
lung parenchyma, including that adjacent to tal pulmonary nodule or mass. This sign was drainage. Lung abscess is most commonly
interlobar fissures. Although initially originally thought to indicate hematogenous associated with aspiration pneumonia and
thought to be diagnos- dissemination of disease [20, 21], but when septic pulmonary emboli. Common causative
tic of mycobacterial infection, the tree-in- it was studied on multiplanar reformatted organisms include anaerobes,
bud sign may be an imaging manifestation of images, most of the so-called feeding ves- Staphylococcus aureus, and Klebsiella
various infections caused by bacteria, fungi, sels were actually pulmonary veins coursing pneumoniae. Lung ab- scess is associated
parasites, and viruses [6, 8, 10]. Tree-in-bud from the nodule, and the pulmonary arteries with increased morbidity and mortality.
opacities usually indicate infectious bron- usually coursed around the nodule [22]. The Prompt detection at imaging
chiolitis or aspiration but are less common- feeding vessel sign was initially considered
ly seen in other conditions, such as follicular diagnostic of septic emboli (Fig. 6) but has
bronchiolitis, chronic airways inflammation
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studies may improve patient care, enabling causes of this sign include parapneumonic nant effusions (Fig. 10), hemothorax, and se-
clinicians to treat patients with an appropri- and malig- quelae of previous talc pleurodesis, lobecto-
ate course of antibiotic therapy [27]. my, or pneumonectomy. Hemothorax usually
Detection of an air-fluid level at chest has associated heterogeneously high attenua-
radi- ography should prompt evaluation of its tion, and talc pleurodesis has attenuation sim-
loca- tion as being in the lung parenchyma or ilar to that of calcium and is often clumped.
with- in the pleural space. A lung abscess
with an air-fluid level can be differentiated Halo Sign
from em- pyema with bronchopleural fistula The halo sign is the CT finding of a periph-
by mea- surement and comparison of the eral rim of ground-glass opacity surrounding
lengths of the visualized air-fluid level on a pulmonary nodule or mass [2, 32]. When
orthogonal chest radiographs. Because of the detected in a febrile patient with neutrope-
charac- teristic spherical shape of a lung nia, this sign is highly suggestive of angio-
abscess, an associated air-fluid level invasive Aspergillus infection [3234] (Fig.
typically has equal lengths on 11). The ground-glass opacity represents
posteroanterior and lateral chest radiographs hemorrhage surrounding infarcted lung and is
(Fig. 8). By contrast, empyema typically caused by vascular invasion by the fungus
forms lenticular collections of pleu- ral [35]. The halo sign is typically seen early in
fluid, and an associated air-fluid level the course of the infection. In a group of 25
(e.g., bronchopleural fistula) usually exhibits patients with invasive Aspergillus infection,
length disparity when compared on postero- the halo sign was seen in 24 patients on day 0
anterior and lateral chest radiographs. In ad- and was detected in only 19% of patients by
dition, both entities typically display a differ- day 14, highlighting the importance of per-
ence in the angle of their interface with an forming CT early in the course of a suspect-
adjacent pleural surface. A lung abscess usu- ed fungal infection [36]. In a large group of
ally forms an acute angle when it intersects immunocompromised patients with Asper-
with an adjacent pleural surface, and its wall gillus infection, Greene and colleagues [37]
is often thick and irregular. By contrast, em- found that patients in whom the halo sign was
pyema typically forms obtuse angles along visualized at CT had improved surviv- al and
its interface with adjacent pleura and usu- response to antifungal treatment com- pared
ally has smooth, thin, enhancing walls [28, with those without the halo sign at CT.
29]. Other differential diagnostic consider- Differential considerations for the halo sign
ations for an intrathoracic air-fluid level in- include other infections, such as mucormy-
clude hemorrhage into a cavity, lung cancer, cosis and Candida (Fig. 12), Pseudomonas,
and metastatic disease. herpes simplex virus, and cytomegalovirus
infections, and other causes, such as Wegen-
Split-Pleura Sign er granulomatosis, hemorrhagic metastasis,
Normal visceral and parietal pleura are in- and Kaposi sarcoma [38, 39].
distinguishable on CT images. In the presence
of an exudative pleural effusion with locula- Air Crescent Sign of Angioinvasive
tion, inflammatory changes may thicken both Aspergillus Infection
the visceral and parietal pleura that surround The air crescent sign is the CT finding of a
the fluid collection and may become evident crescentic collection of air that separates a
as the split-pleura sign, suggesting the pres- nodule or mass from the wall of a surround-
ence of empyema [28, 30]. A loculated effu- ing cavity [2]. This sign is seen in two types
sion may have an atypical chest radiographic of Aspergillus infection: angioinvasive and
appearance when located within a fissure. mycetoma [40]. In angioinvasive Aspergillus
The split-pleura sign may be seen in infection, the sign is caused by parenchymal
combination with the air-fluid level sign cavitation, typically occurs 2 weeks after de-
when a broncho- pleural fistula occurs within tection of the initial radiographic abnormal-
empyema. ity, and coincides with the return of neutro-
Empyema should be considered when a phil function (Fig. 13). The air crescent sign is
patient presents with fever, cough, and chest suggestive of a favorable patient prognosis
pain and CT shows the split-pleura sign. In a [41]. The intracavitary nodule represents ne-
series of 58 patients with empyema, the split- crotic, retracted lung tissue that is separated
pleura sign was seen in 68% [30] (Fig. 9). from peripheral viable but hemorrhagic lung
The split-pleura sign is not specific for parenchyma seen as outer consolidation or
empyema but rather indicates the presence of ground-glass opacity [42].
an exuda- tive effusion [31]. Other important

48 AJR:202, March 2014 AJR:202, March 2014 48

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Air Crescent or Monad Sign Finger-in-Glove Sign The tubular opacities that occur in ABPA
of Mycetoma The finger-in-glove sign is the chest result from hyphal masses and mucoid im-
The air crescent sign of mycetoma, also radio- graphic finding of tubular and paction and typically affect the upper lobes.
re- ferred to as the Monad sign, is seen in an branching tubu- lar opacities that appear to In 1928% of cases, the endobronchial opac-
im- munocompetent host with preexisting emanate from the hila, said to resemble ities in ABPA may be calcified or
cystic or cavitary lung disease, usually from gloved fingers [45, 46]. The tubular hyperatten- uating on unenhanced CT
tuber- culosis or sarcoidosis [42]. The fungal opacities represent dilated bronchi impacted images (Fig. 15), probably because of the
ball or mycetoma develops within a with mucus. The CT finger-in-glove sign is presence of calcium salts, metals, and
preexisting lung cavity and may exhibit branching endobronchial opacities that desiccated mucus [4750].
gravity dependence (Fig. 14). The mycetoma course alongside neighboring pulmonary ar-
is composed of fun- gal hyphae, mucus, and teries. The finding is classically Crazy-Paving Sign
cellular debris. My- cetomas can cause associated with allergic bronchopulmonary The crazy-paving sign is the CT finding of
hemoptysis. The treatment options include aspergillosis (ABPA), seen in persons with a combination of ground-glass opacity and
surgical resection, bronchial artery asthma and pa- tients with cystic fibrosis smooth interlobular septal thickening that re-
embolization, and instillation of anti- fungal (Fig. 15), but may also occur as an imaging sembles a masonry pattern used in walkways
agents into the cavity [40]. The air cres- cent manifestation of en- dobronchial tumor [2]. The crazy-paving sign was originally de-
sign is not specific for Aspergillus infec- tion (Fig. 16), bronchial atresia, cystic fibrosis, scribed as a characteristic CT pattern detect-
and can be seen in other conditions, such as and postinflammatory bronchi- ectasis [45 ed in patients with pulmonary alveolar pro-
cavitating neoplasm, intracavitary clot, and 47]. Bronchoscopy may be nec- essary to teinosis. The sign has come to be recognized,
Wegener granulomatosis [2, 43, 44]. exclude endobronchial tumor as the cause however, as occurring in many other condi-
of the finger-in-glove sign.

48 AJR:202, March 2014 AJR:202, March 2014 48

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tions, including infection (e.g., Pneumocystis trilobular nodules are evenly spaced and do The hydatid cyst is composed of three lay-
jiroveci pneumonia, influenza, and infections not come into contact with adjacent pleural ers: an outer protective barrier consisting
by other organisms) [51, 52]. In surfaces. Perilymphatic nodules are distribut- of modified host cells, called the pericyst; a
Pneumocystis pneumonia, the histologic ed along peribronchovascular structures, the middle acellular laminated membrane, called
features that pro- duce the crazy-paving subpleural lung, and along interlobular sep- the ectocyst; and an inner germinal layer that
pattern are alveolar exudates containing the ta. Random nodules forming the miliary pat- produces scolices, hydatid fluid, daughter
infective organisms and cellular infiltration tern are distributed uniformly throughout the vesicles, and daughter cysts, called the en-
or edema in the alveo- lar walls and lungs, and those in the periphery may come docyst [74, 75, 77]. The meniscus, Cumbo,
interlobular septa [52, 53]. An- cillary into contact with a pleural surface [61, 62]. and water lily signs are all seen with pulmo-
clinical or radiographic features sug- gestive Noninfectious causes of the miliary pattern nary echinococcal infection [7478]. These
of Pneumocystis pneumonia include a include metastatic disease, IV injected for- signs are caused by air dissecting between
history of immunosuppression, imaging eign material, and rarely sarcoidosis [62, 63]. the cyst layers, which are initially indistin-
findings of pulmonary cysts, and the occur- guishable on CT images because the cysts
rence of secondary spontaneous pneumotho- Reverse Halo and Birds Nest Signs are fluid filled (Fig. 22). With bronchial
rax [54] (Fig. 17). The reverse halo sign is the CT finding of erosion, air dissects between the outer
Differential diagnostic considerations for peripheral consolidation surrounding a cen- pericyst and ectocyst to produce the
the crazy-paving sign can be categorized tral area of ground-glass opacity [64]. As- meniscus sign (Fig.
according to the typical time course of the sociated irregular and intersecting areas of 23). Some radiologists believe that the me-
suspected diseases (Fig. 18). Diseases char- stranding or irregular lines may be present niscus sign is suggestive of impending cyst
acterized by an acute time course include within the area of ground-glass opacity and rupture [76, 77]. As it accumulates further,
pulmonary edema, pulmonary hemorrhage, become evident as the birds nest sign [65] air penetrates the endocyst layer and causes
and infection. Those with a more chronic (Fig. 21). These signs are suggestive of in- the Cumbo sign, which comprises an air-flu-
course include pulmonary alveolar proteino- vasive fungal infection (e.g., angioinvasive id level in the endocyst and a meniscus sign
sis, pulmonary adenocarcinoma, and lipoid Aspergillus infection or mucormycosis) in (Fig. 23). Finally, the endocyst layer collaps-
pneumonia [52, 55]. susceptible patient populations [66]. Major es and floats on fluid, forming the water lily
predisposing factors for fungal infection in- sign (Fig. 24).
Grape-Skin Sign clude stem cell or solid organ transplant, he-
The grape-skin sign is the radiographic or matologic malignancy, diabetic Burrow Sign of Paragonimiasis
CT finding of a very thin-walled cavitary ketoacidosis, and a depressed immune Paragonimiasis is a zoonotic parasitic in-
le- sion that develops in lung parenchyma system. Imaging fea- tures that favor fection caused by lung flukes [79]. Humans
pre- viously affected by consolidation or mucormycosis over Aspergillus infection in a serve as a definitive host when they ingest
lung granulomas that have undergone neutropenic patient are detec- tion of the raw or improperly cooked crab or crayfish
central ca- seous necrosis [56]. As reverse halo or birds nest sign, multiplicity [76]. Paragonimus westermani and
classically described, the grape-skin sign is of pulmonary nodules (> 10), and Paragonimus kellicotti are the two
a solitary finding of a thin-walled cavity development of infection despite vori- pathogens endemic to Asia and North
with central lucency that has been conazole prophylaxis [6668]. The reverse America, respectively. They produce similar
associated with chronic pulmonary halo and birds nest signs are not specific imaging findings in the tho- rax [7983].
coccidioidomycosis infection [57, 58] for invasive fungal infection and may also The chest CT findings reflect the life cycle
(Fig. be seen in other conditions, including of the parasite. The second form of the imma-
19). Over time the lesion may deflate, or it crypto- genic organizing pneumonia, ture organism lives in the crab or crayfish.
may rupture into the pleural space, the result bacterial pneu- monia, Af- ter ingestion by a mammal, the parasite
being pneumothorax [56, 59]. The differen- paracoccidioidomycosis, tuberculo- sis, pen- etrates through the small bowel to enter
tial diagnosis of this finding includes other sarcoidosis, Wegener granulomatosis, and the peritoneal cavity, where it incites an
solitary cavitary or cystic lesions, such as pulmonary infarction [64, 6873]. inflam- matory reaction. Several weeks later,
re- activation tuberculosis infection, the or- ganism migrates through the
pneumato- cele, neoplasm (e.g., primary Meniscus, Cumbo, and Water Lily diaphragm to en- ter the pleural space. After
lung cancer or metastasis), and other fungal Signs of Echinococcal Infection finding mates, the parasites burrow through
infections. Pulmonary hydatid disease is a zoonotic the visceral pleura into the lung parenchyma,
parasitic infection caused by the larval stage where they produce cysts that contain eggs.
Miliary Pattern of Echinococcus tapeworms [74]. This ge- The eggs are extrud- ed into bronchioles and
The miliary pattern consists of multiple nus of worms is endemic in Alaska, South expectorated by the infected mammal to
small (< 3 mm) pulmonary nodules of America, the Mediterranean region, Africa, complete the life cycle [79]. The burrow sign
similar size that are randomly distributed and Australia. Humans can serve as interme- is a linear track extend- ing from the pleural
throughout both lungs [2]. This pattern diate hosts after contact with a definitive surface or hemidiaphragm to a cavitary or
implies hematog- enous dissemination of host (e.g., dog or wolf) or after consuming cystic pulmonary nodule. The linear track
disease and is clas- sically associated with con- taminated vegetables or water [74]. The represents the path followed by the worms
tuberculosis but can also be seen with other lung is the second most common organ within the lung, and the cavitary or cystic
infections, such as histoplasmosis and involved, after the liver, and is infected by pulmonary nodule contains both the adult
coccidioidomycosis, par- ticularly in either hema- togenous or direct worms and their eggs (Fig. 25). There is often
immunocompromised individuals [60] (Fig. transdiaphragmatic spread from the liver associated pleural effusion, omental fat
20). Random pulmonary nodules must be [7476].
differentiated from those with a cen-
trilobular or perilymphatic distribution. Cen-
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stranding, and anterior cardiophrenic and in- 11. Li Ng Y, Hwang D, Patsios D, Weisbrod G. 817820
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(Figures start on next page)

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Fig. 1 49-year-old man with left lower lobe pneumonia. Example of air Fig. 2 4-year-old girl with lingular pneumonia. Example of silhouette sign.
bronchogram sign. Posteroanterior radiograph (left ) and coronal CT image Posteroanterior radiographs show normal interface (right ) and loss of normal
(right ) show left lower lobe consolidation and air bronchogram sign (arrows). interface of lung and left-heart border (left ), thus localizing abnormality to

Fig. 3 45-year-old man with reactivation tuberculosis. Example of tree-in-

bud sign. Photograph (top) shows budding tree. A xial CT image (bottom)
shows numerous V- and Y-shaped tree-in-bud opacities.
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Fig. 4 40-year-old man after IV injection of crushed Fig. 575-year-old man with alcoholism and Klebsiella pneumonia. Example of bulging fissure sign.
morphine sulfate tablets. Example of tree-in-bud Posteroanterior (left ) and lateral (right ) radiographs show right upper lobe consolidation causing
sign. Axial maximum-intensity-projection image inferior bulging of minor fissure (black arrows), posterior bulging of major fissure (white arrow), and
shows diffuse vascular tree-in-bud opacities and inferomedial displacement of bronchus intermedius (asterisk).
dilated main pulmonary arteries. Similar findings
all aspects of both lungs. Infectious bronchiolitis or
aspiration is unlikely to result in such diffuse
bilateral distribution of tree-in-bud opacities, and
other conditions, such as diffuse panbronchiolitis
and injection of foreign material, as in this case,
should be considered as alternative diagnoses.

Fig. 6 45-year-old man with septic emboli. Example of feeding vessel sign. Fig. 755-year-old man with necrotizing aspiration
Coronal CT image shows septic pulmonary emboli manifesting themselves as pneumonia. Example of inhomogeneous
peripheral solid and cavitary pulmonary nodules of varying sizes. Many enhancement. Axial contrast-enhanced CT image
nodules exhibit feeding vessel sign (arrows). shows heterogeneously enhancing right lower lobe
consolidation (arrows) suspicious for early
pulmonary necrosis. Also present are foci of air
(arrowheads) representing early abscess formation
and small loculated right pleural effusion (asterisks).
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Fig. 835-year-old man with Staphylococcus aureus pneumonia forming lung abscess. Example of air-fluid level sign.
A, Posteroanterior (left ) and lateral (right ) radiographs show right lower lobe cavity with air-fluid level (arrows) of equal length on both orthogonal views. Thick,
irregular wall typical of lung abscess is evident.
B, Axial CT image shows parenchymal location of right lower lobe cavity with air-fluid level, irregular internal contours, and associated bronchus (arrow) coursing to lesion.

Fig. 948-year-old woman with empyema. Example of split-pleura sign. Axial (left) Fig. 10 65-year-old man with malignant pleural effusion. Example of split-
and sagittal (right) contrast-enhanced CT images show thickened visceral pleura sign. A xial (left ) and sagittal (right ) contrast-enhanced CT images show
(arrowhead) and parietal (white arrows) pleura separated from their normal state of thickening of visceral (arrowheads) and parietal (arrows) pleura with associated
apposition (i.e., split) to surround loculated empyema. Adjacent atelectasis is evident effusion. Split-pleura sign only indicates presence of exudative effusion and must
in right lower lobe. Split-pleura sign is not specific for empyema but rather indicates be
presence of exudative effusion. Chest tube is incompletely visible (black arrows). correlated with clinical findings and thoracentesis to establish accurate diagnosis.
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Fig. 1135-year-old man with fever, neutropenia, and angioinvasive Fig. 12 47-year-old man with disseminated candidiasis. Example of halo
Aspergillus infection. Example of halo sign. Posteroanterior radiograph and sign. A xial CT image shows multiple bilateral pulmonary nodules with
axial CT image show right upper lobe mass with peripheral ground-glass surrounding ground-glass opacity.
opacity (arrows) constituting halo sign.

Fig. 1338-year-old man with angioinvasive Aspergillus infection. Example Fig. 14 65-year-old woman with intracavitary mycetoma. Example of air
of air crescent sign. Axial (left ) and coronal (right ) CT images show air crescent or Monad sign. A xial supine (left ) and prone (right ) CT images
crescent sign (arrows), which occurs in immunocompromised patients with show gravity dependence of fungal ball (mycetoma). Air crescent sign of
recovering mycetoma occurs in immunocompetent patients. Fungus ball develops within
neutrophil levels. Intracavitary nodule (asterisks) represents necrotic lung preexisting cavity, usually in association with tuberculosis or sarcoidosis.
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Fig. 1525-year-old
woman with allergic
aspergillosis (ABPA).
Example of finger-in-
glove sign.
A, Posteroanterior
radiograph shows
branching tubular
opacities (arrows)
emanating from both hila.
B, Unenhanced axial
(left ) and oblique
sagittal (right ) CT
images show branching
tubular opacities
with high attenuation.
Opacities in ABPA are
composed of hyphal
masses, and mucoid
impaction and may be
calcified on CT images in
as many as 28% of cases.


Fig. 16 63-year-old man with squamous cell lung cancer. Example of finger-in- Fig. 1724-year-old man with HIV infection and
glove sign. Posteroanterior radiograph (top left ) and corresponding coronal (top Pneumocystis pneumonia. Example of crazy-paving
right ) and axial (bottom) CT images show branching tubular opacity (arrows) in sign. A xial CT image shows diffuse ground-glass
right upper lobe. Proximal portion of branching opacity was FDG avid (not opacity with areas of superimposed interlobular
shown) and represented tumor, whereas rest of opacity represented mucoid septal thickening (combination that forms crazy-
impaction in dilated bronchus. paving pattern) and multiple thin-walled cysts. In
HIV-positive patient with dyspnea, findings are most
consistent with Pneumocystis pneumonia.
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Fig. 18CT scans show crazy-paving sign in patients with various disorders. Differential diagnostic
considerations are influenced by patients clinical presentation and disease course. In patients with acute
symptoms, crazy-paving sign may represent pulmonary edema, pulmonary hemorrhage, or infection. In
patients with chronic symptoms, crazy-paving sign may represent lipoid pneumonia, lung cancer, or pulmonary
alveolar proteinosis (PAP).

Fig. 2029-year-old man with AIDS (CD4 count,

Fig. 1955-year-old man with chronic 10/L) and disseminated histoplasmosis. Example of
coccidioidomycosis infection. Example of grape-skin miliary pattern. A xial CT image shows multiple small
sign. Posteroanterior radiograph shows thin-walled pulmonary nodules distributed uniformly throughout
grape-skin cyst (arrows). Axial CT image (inset ) both lungs. Some nodules are in contact with major
shows that over time cavity may deflate and acquire fissure and subpleural lung and have no relation to
slightly thicker wall. secondary pulmonary lobules. Differential
considerations for randomly distributed pulmonary
nodules include miliary infection (e.g., tuberculosis,
histoplasmosis), metastatic disease, and rarely
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Fig. 21 44-year-old man with febrile neutropenia and pulmonary

mucormycosis. Example of reverse halo and birds nest signs. A xial (left ) and
coronal (right ) CT images show peripheral rim of consolidation (arrows)
surrounding central ground- glass opacity, reticulation, and nodularity. This
appearance has been likened
to birds nest and reverse halo. Early diagnosis of mucormycosis pneumonia is
imperative because standard voriconazole therapy is not effective for
treatment. (Courtesy of Chou S, University of Washington, Seattle, WA)

Fig. 22Drawings show normal hydatid cyst and meniscus, Cumbo, and water lily signs. (Courtesy of Loomis
S, REMS Media Services, Mass General Imaging, Boston, MA)

49 AJR:202, March 2014 AJR:202, March 2014 49

1 1
Fig. 23 49-year-old man with pulmonary hydatid disease. Example of meniscus Fig. 2427-year-old woman with pulmonary hydatid
(left ) and Cumbo (right ) signs. Chest CT images show air between pericyst and disease. Example of water lily sign. Posteroanterior
ectocyst layers (arrows) consistent with meniscus sign. Air-fluid level in radiograph shows large right lower lobe thick-
endocyst (arrowhead ) in combination with meniscus sign forms Cumbo sign. walled cavity with lobulated airsoft-tissue
(Courtesy of Rossi S, Centro de Diagnostico Dr Enrique Rossi, Buenos Aires, interface representing floating endocyst (arrow ).
Argentina) Coronal
CT image (inset ) from earlier examination
shows unruptured cyst.

49 AJR:202, March 2014 AJR:202, March 2014 49

2 2
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Fig. 2532-year-old man with North American paragonimiasis after ingestion of raw cray fish. Example of burrow sign. (Courtesy of
Henry T, Emory University, Atlanta, GA)
A, Axial CT images in soft-tissue (left ) and lung (right ) windows shows linear burrow track (arrows) extending from thickened pleura
to pulmonary nodule.
B, Axial CT image shows long linear burrow track (arrow ) in right upper lobe and small pneumothorax.


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