Pneumonia: Playing Hide And Seek

It is important to know when your patient can have pneumonia

, yet it is not seen on a CXR.

You can have a patient who is clinically sick because of a pneumonia, but when you do an x-ray you just dont see it there. There are three answers.

One is dehydration. A patient who is dry will not waste water on hydration of a lung that is infected. Any patient that is dehydrated, it is reasonable to make the diagnosis of pneumonia without radiographic evidence. You would put in your notes that the patient is clinically dehydrated, and I am confident that when hydrated the next day, and we again x-ray, a pneumonia will become apparent.

Chronic obstructive pulmonary disease patients can have pneumonia and not have it readily apparent on the chest radiograph. Remember that the pathology of COPD is that they have air trapping. They have a relatively large amount of air in their chest, and this can dilute the concentration of the opacity, making it mare difficult to see. COPD patients are treated with antibiotics. COPD exacerbations are assumed to have a bacterial infection until proven otherwise. Of contrast, in asthma patients we understand the pathophysiology does not include infectious disease. So, when someone comes in with an asthma attack, very rarely would we put them on an antibiotic as opposed to someone with chronic obstructive pulmonary disease who we always place on antibiotics.

Lastly is a retrocardiac (or lingula) pneumonia. This is where behind the heart there is a pneumonia that would not be seen on an AP film. You would need to use a lateral film. It's extremely difficult to evaluate a patient that has an under penetrated CXR. If they have a well penetrated film and you can see the vertebral bodies, you may be able to make out a lingula pneumonia on the chest x-ray. If not, you really need to get a lateral radiograph. Pneumonia that is in the lower fields, touching the diaphragm, may cause abdominal pain and be the patient's chief complaint. So, someone comes in with abdominal pain and a fever, you have to be concerned about whether this could be a pneumonia in the lower fields of the lung. Lets say you have a child who comes in with a fever and abdominal pain. You think appendicitis. The surgeon takes him into the operating room, removes the appendix and admits him to the hospital. In the postoperative phase, these patients are not placed on antibiotics. This could lead to a life threatening infection/sepsis. With all said, when can you have an infected lung and not see it radiographically? Dehydration, chronic obstructive pulmonary disease, and retrocardiac or lingular pneumonia.

by: Carl Davidson

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