645

Candida albicans
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Pneumonia: Radiographic
Appearance

Samuel J. Buff A retrospective series of patients with pure Candida albicans pulmonary opportun-
Robert McLelIand2 istic infection confirmed at autopsy were examined for any characteristic radiographic
Harry A. Gallis3 pattern. Of the 20 patients examined, eight showed nonlobar, nonsegmental, bilateral
disease; the others exhibited unilateral or bilateral lobar or segmental patterns. Cavi-
Richard Matthay4
tation, adenopathy, masslike opacities, or a miliary pattern were not identified. Radio-
Charles E. Putman1
graphically these “negative” findings can be useful in distinguishing Candida from
other fungal opportunistic infections. Histologic evidence of lung invasion by Candida
is necessary for definitive confirmation. The previously described association of Can-
dida infection with certain underlying diseases (leukemia and lymphoma) was again
demonstrated.

Opportunistic infection in the compromised host is associated with a significant

morbidity and mortality. Opportrinistic pulmonary infections can be seen as an
isolated entity or as part of a generalized systemic infection. Accurate and rapid
diagnosis of the infection is necessary in order to implement appropriate therapy.
Even though bronchoscopy or open lung biopsy is often required to make a
definitive diagnosis, the chest radiograph can be an invaluable tool in these
patients to offer clues as to the source and etiology of opportunistic infections.
The radiographic pattern can be useful in excluding as well as including differ-
ential possibilities and can be correlated with bronchoscopic or lung biopsy
findings.
In prior reports on opportunistic infections [1 -5], Candida species have alwayE
been included in the list of possible etiologies. Because Candida is a normal
inhabitant of the oropharynx and gastrointestinal tract, cultures of these orga-
nisms and other methods short of open lung biopsy have always been suspect in
implicating Candida as the etiologic agent in an opportunistic pulmonary or
systemic infection. Candida is usually seen as part of a mixed infection, and the
typical patterns Candida
of pneumonia in pure form have not been well docu-
mented. To determine if there is a consistent or predictive radiographic pattern
Received October 5, 1 981 : accepted after re-
of Candida pneumonitis, a population of compromised hosts at Duke University
vision December 30, 1 981.
Medical Center and Yale-New Haven Medical Center with autopsy-proven iso-
Department of Radiology, Duke University
Medical Center, Durham, NC 27710. Address re-
lated Candida pulmonary infections were analyzed. The radiographic findings
print requests to C. E. Putman (Box 3808). were tabulated to determine the more common presenting patterns as well as
2Department of Medicine, Duke University Med- distinguishing Candida from other opportunistic infections.
ical Center, Durham, NC 27710.

3Department of Radiology, University of North

Carolina School of Medicine, Chapel Hill, NC Materials and Methods
27514.
The medical records and autopsy reports of all patients diagnosed as having systemic or
4Department of Medicine, Yale-New Haven
Medical Center, New Haven, CT 06504. pulmonary candidiasis at Duke University Medical Center and Yale-New Haven Medical
AJR 138:645-648, April 1982 Center for the years 1 970-1 980 were reviewed. The patients with mixed infections
0361 -8o3x/82/1 384-0645 $00.00 documented clinically, histologically, or on postmortem culture of the lung were excluded
© American Roentgen Ray Society from the study. Only patients with Candida a!bicans as the sole organism found in the lung
 646 BUFF ET AL. AJR:138, April 1982
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Fig. 3.-i 7-year-old with acute leukemia. PA radiograph. Homogeneous

consolidation in left lung with obliteration of left hemidiaphragm. Rtght basilar
mixed infiltrate.
Fig. 1 -18-year-old with leukemia and acute respiratory failure. Antero-
posterior (AP) radiograph before death. Diftuse inhomogeneous opacities
consistent with mixed alveolar-interstitial process. At autopsy, extensive
invasive Candida pneumonitis was found.

Fig. 2-22-year-old with choriocarcinoma. AP radiograph. Bibasilar air- Fig. 4-56-year-old with metastatic cancer. AP radiograph. Mixed alveo-
space opacities, right greater than left. ar and interstitial changes in left upper lobe; dense consolidation in right
base and medial segment of right middle lobe.

on postmortem culture and/or histologically invasive into the IunQ All of our patients with pulmonary Candida infections were
parenchyma were included. The chest radiographs of these patients compromised hosts. Over one-half of our patients (1 1 of 20)
were reviewed and only patients whose last chest radiograph was had lymphoma or leukemia as an underlying illness. Of the
within 48 hr of the time of death were included. The radiographic 20 patients, 1 1 were being treated with chemotherapeutic
findings of the patients who met these criteria were tabulated to
agents for their underlying illness. Four patients developed
determine the most common patterns in pure Candida pulmonary
their opportunistic infection in the immediate postoperative
infections and distinguishing features from other opportunistic in-
period. The rest of our patients had other forms of cancer
fections.
or other debilitating illnesses.
Candida pulmonary infections showed varied manifesta-
Results
tions on chest radiographs. The distribution was air space
Twenty cases of isolated Candida pulmonary infection in all our patients, but with an interstitial component in 1 1.
meeting the above criteria were found. Of these, three Eight patients had bilateral disease without a specific lobar
infections were limited solely to the lungs, while in 1 7, or segmental distribution. In these patients, radiographs
multiorgan involvement by Candida was found at autopsy. showed homogeneous or patchy, poorly defined areas of
 AJR:138, April 1982 CANDIDA ALBICANS PNEUMONIA 647

by Pagani and Libshitz [1 3] was not seen in our patients,

nor was it seen in the series of pediatric cases compiled by
Kassner et al. [1 2]. This fine nodular pattern could be
secondary to concomitant pulmonary pathology or could
represent an earlier manifestation of disseminated candidi-
asis than seen in our patients.
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Even though the findings in our series were nonspecific

for Candida and overlap with the findings in other opportun-
istic infections, certain ‘ ‘ negative’ ‘ findings can assist in
separating Candida infections from other opportunistic in-
fections. Cavitation was not seen in any of our patients with
Candida pulmonary infections, whereas cavitation is promi-
nent on the chest radiographs of such organisms as Nocar-
dia, Aspergillus, and Mucoraceae. Cavitation can also rarely
be seen in Cryptococcus. Thus the presence Of cavitation
can implicate these organisms as differential possibilities
while excluding predominant invasive candidiasis. Masslike
Fig. 5-25-year-old woman with acute leukemia. PA radio9raph. Air- lesions, seen especially in Cryptococcus but also in Nocar-
space consolidation In right lower lobe and middle lobe.
dida, Aspergillus, and Mucoraceae, were not seen in our
Candida series and is another useful differential finding.
parenchymal involvement (figs. 1 -3). Eight patients had Although tuberculosis is not commonly considered an op-
bilateral lobar disease, and the other four had unilateral portunistic infection, tuberculosis is a common pathogen in
disease (three lobar, one segmental) (figs. 4 and 5). Five debilitated hosts. Cavitation and miliary spread, typical find-
patients manifested pleural effusions, and all were exudates. ings in tuberculosis infections, were not seen in our series.
The precise lobar distribution (including multilobar involve- Extension across the pleural space into the chest wall,
ment) was evenly distributed between left and right lungs. In which can be seen in disease from the organisms Actino-
none of our patients was a miliary pattern or large masslike myces, Nocardia, Mycobacterium, or Cryptococcus, was
opacity seen. Cavitation and hilar or mediastinal adenopathy also not demonstrated in any of our patients.
were not identified in our series of patients with pure Can- In our series of patients, Candida opportunistic infection
dida pulmonary infection. was a major or the major factor contributing to the patient’s
demise. None of our patients recovered from their infection,
even though appropriate therapy was instituted in several
Discussion
cases. Clinicians need to be made aware that in certain
Our series of patients correlates with previous studies clinical settings and with certain radiographic patterns, Can-
associating Candida with certain underlying illnesses, es- dida should be a serious consideration as to the etiology of
pecially lymphoma and leukemia (1 1 of 20 in our study). an opportunistic infection. Appropriate antibiotic therapy
Over one-half of our patients were on chemotherapy at the should be instituted at the earliest time to try to improve on
time they developed their Candida infection, which again the current dismal prognosis. Even though specific radio-
correlates with the findings of others [2, 5, 6]. The previously graphic patterns were not identified, inclusion of Candida
reported dissemination in the postoperative period [6, 7] as a differential possibility when a diffuse or lobar pattern is
was seen in four of our patients. seen in a compromised host may expedite definitive proce-
In our patients, no attempt was made to divide them into dures such as lung biopsy or bronchoscopy. If other radio-
groups according to a presumed aspiration or hematoge- graphic patterns are observed, concomitant or alternative
nously acquired disease. Multiorgan involvement (1 7 of our pathogens should be considered.
20 patients) implicates hematogenous dissemination as the
most likely avenue of spread. In these patients, Candida
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