Pediatr Radiol (2007) 37:12351240 DOI 10.

1007/s00247-007-0654-3

ORIGINAL ARTICLE

Round pneumonia: imaging findings in a large series of children

Yong-Woo Kim & Lane F. Donnelly

Received: 26 July 2007 / Revised: 23 August 2007 / Accepted: 7 September 2007 / Published online: 19 October 2007 # Springer-Verlag 2007

Abstract Background Although round pneumonia is a well-known clinical entity, there have been no large case reviews, with most knowledge based on case reports and small series from the 1960s and 1970s. Objective To review the imaging findings of a large series of children with round pneumonia. Materials and methods A retrospective review of radiographic and CT findings in all children reported to have round pneumonia at a large childrens hospital from 2000 to 2006 was performed. Children with underlying medical conditions were excluded. Epidemiologic characteristics, radiographic and CT findings, and follow-up imaging were reviewed. Results The review identified 109 children (mean age 5 years, range 4 months to 19 years). Round pneumonias tended to be solitary 98% (107/109), have well-defined borders 70% (77/ 109), and be posteriorly located 83% (91/109), with the following lobar distribution: left lower lobe (36), right lower lobe (33), right upper lobe (28), left upper lobe (7), right middle lobe (4), and lingula (2). Round pneumonia tended to resolve on follow-up imaging (95%, 41/43) as compared to progression to lobar pneumonia (4.6%, 2/43). Three patients (2.6%, 3/112) originally suspected to have round pneumonia were later shown to have other diagnoses: cavitary necrosis in pneumonia (two) or pleural pseudocyst (one). Conclusion Round pneumonia occurs in young children (mean age 5 years), tends to be a solitary lesion, and is most

commonly posteriorly located. Misdiagnosis of other pathology as round pneumonia is uncommon. Keywords Chest radiography . CT . Round pneumonia . Lung . Infection . Children

Introduction Round pneumonia is generally thought to be a disease of children and has been only infrequently reported in adults [1, 2]. Most round pneumonias present in children with fever, malaise, and cough. Chest radiography is the primary imaging study to diagnostically evaluate children with the possibility of round pneumonia. CT is sometimes used in patients in whom the diagnosis is uncertain to exclude other diagnoses. Round pneumonia may also be seen on the most superior images of an abdominal CT scan or radiographs obtained for evaluation of abdominal pain. Although round pneumonia is a well-described clinical entity, with the exception of case reports, very little has been published concerning imaging findings [310]. A review of the literature showed no large series published [213]. We retrospectively reviewed the clinical records, chest radiographs, and CT findings in a large series of children with round pneumonia. The purpose of the review was to evaluate the size, location, shape, margin, and associated findings of round pneumonia in children as compared to the published literature in adults.

Y.-W. Kim : L. F. Donnelly (*) Department of Radiology, Cincinnati Childrens Hospital Medical Center, 3333 Burnet Avenue, MLC 503, Cincinnati, OH 45229-3039, USA e-mail: Lane.Donnelly@cchmc.org

Materials and methods Children with round pneumonia were identified by word search of radiology reports at a large childrens hospital from

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Fig. 1 A 6-year-old boy with fever and cough. Posteroanterior (a) and lateral (b) chest radiographs show a well-defined mass (arrows) in the left lower lobe

2000 to 2006. Children with underlying medical conditions were excluded. Initially, we identified 112 children who were originally suspected to have round pneumonia on radiology report. Three patients (2.6%, 3/112) were later shown to have other diagnoses and were excluded from the study group. We retrospectively reviewed the clinical and imaging findings in 109 children reported to have round pneumonia. Epidemiologic characteristics, radiographic and CT findings, and follow-up imaging were reviewed. Epidemiologic characteristics included the patients age, gender, underlying disease, and clinical symptoms. Imaging studies were evaluated by two reviewers simultaneously with opinions reached by consensus. The initial chest radio-

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Fig. 2

A 4-year-old boy with fever and right lower quadrant abdominal pain. a Chest radiograph demonstrates a well-circumscribed mass (arrow) in the left lower lobe. b, c Lung images on abdominal CT scan obtained for suspected appendicitis reveal a well-defined, round mass lesion in the posterobasal aspect of the left lower lobe (b abdominal window, c lung window)

graphs and CT scans were evaluated for the following lesion parameters: number, size, margin, and location. Lesion margin was defined as either sharp or indistinct. One or the other modifier was given to each case. Mean age and age range were compared between the sharp and indistinct margin groups. Follow-up chest radiographs were evaluated for temporal change (resolution or progression to lobar pneumonia). The time interval between initial and follow-up radiography was recorded. We evaluated alternative diagnoses in three patients (2.6%, three of the initially identified 112) who were originally suspected to have round pneumonia and were later shown to have other diagnoses. This investigation was approved by the Institutional Review Board.

Results The mean age of the 109 children with round pneumonia included was 5 years and their ages ranged from 4 months to 19 years. The gender ratio was nearly equal (F:M 51:58). The clinical symptoms were fever (92), cough (58), vomiting (9), abdominal pain (7), and chest pain (6). Typical imaging findings are demonstrated in Figs. 1 and 2. Evaluation of chest radiographs showed one lesion in each of 107 children (98%, 107/109) and two lesions in a single child (1/109; Fig. 3). In one child, a lesion was seen on abdominal CT but not on the chest radiograph. Lesion
Fig. 3 Multiple (two) round pneumonia lesions in a 3-yearold boy. a Chest radiography shows two round foci of density (arrows). b Chest CT image shows two round densities in the right lower lobe. Airbronchograms are present

margins were sharp in 70% (77/109) and ill-defined in 30% (32/109). The mean diameter of lesions was 3.8 cm with a range of 112 cm. On lateral chest radiographs, the lesions were seen to be located in the anterior portion (n=8), middle portion (n=6), and posterior portion (n=91). In four children, the lesion was not visible on the lateral chest radiograph. Specific lobar locations (Fig. 4) were left lower lobe (36), right lower lobe (33), right upper lobe (28), left upper lobe (6), right middle lobe (4), and lingula (2). In summary, the location of the lesion tended to be posterior (83%, 91/109) and lower lobe (65%, 71/109). The mean age of children with round pneumonia with a sharp margin was 5.3 years (range 4 months to 16 years) and of those with an indistinct margin 6.8 years (range 15 months to 19 years). Follow-up chest radiographs were obtained in 43 children. Follow-up radiographs tended to show resolution in 95% (41/43; Fig. 5) and progression to lobar pneumonia in 4.6% (2/43). The mean time interval between initial and follow-up radiography was 29.6 days with a range of 6 to 84 days. CT images were available in seven children. Dedicated chest CT was performed in three children and round pneumonia was seen on superior images of abdominal CT scans in four children. On CT images, one lesion was seen in five children, two in one, and three in another. In the child with three lesions seen on CT images, only one lesion was seen on radiographs. The margins of lesions were sharp in six of the seven children and six of the lesions were in the right lower lobe, three were in the left lower lobe, and one was in the right middle lobe. Three patients (2.6%, 3/112) originally suspected to have round pneumonia were later shown to have other diagnoses: cavitary necrosis complicating pneumonia in two children and a focal collection of pleural effusion in the minor fissure (pseudocyst) in one child (Fig. 6). There were no children in whom bronchogenic cysts, other

1238 Fig. 4 Schema shows distribution of lesion locations in round pneumonia in 105 lesions seen on both frontal and lateral radiographs. Lesions are most common in the lower lobes (63%) and posterior locations (83%)

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congenital lesions, or lung neoplasms were originally mistaken for round pneumonia.

Discussion Round pneumonia is a manifestation of pneumonia particular to childhood. It appears as a spherical or rounded lesion on imaging. The typical clinical presentation is that of a mild respiratory infectious prodrome followed by an acute febrile illness. These well-circumscribed areas of inflammation may mimic a primary or metastatic lung tumor and lead to a needless evaluation for neoplasm [1, 2]. In our study, the mean age of the patients was 5 years. In the literature [26], the mean age of patients is 3.3 years. Round pneumonia usually is uncommon after 8 years of age because young children have poorly developed pathways of collateral ventilation (pores of Kohn, channels of Lambert), more closely apposed connective tissue septae, and smaller alveoli than adolescents and adults [1, 5]. These factors likely work together to produce more compact confluent areas of pulmonary consolidation without softer margins evident in typical bacterial infiltrates in adults. In this study, 75% of all patients were under 8 years of age and 90% of patients were under 12 years. In our series, round pneumonia was seen most commonly as a solitary lesion on radiographs (98%). However, we did encounter a child in whom two or three discrete lesions were identified (1%). In the previous literature [13, 14], single lesions were seen in 91%. Kohno et al. [15] suggest that in adults the presence of satellite lesions on CT scans (found in 56% of lesions) is a useful finding in diagnosing round pneumonia. In our study of children, satellite lesions were not seen. This may be due to the fact that underdeveloped interalveolar channels confine the alveolar inflammation and exudation [3]. The typical location of round pneumonia was posterior (83%) and lower lobe (65%) in our series. This is similar to previous studies [13] in which lesions were located in the lower lobes in 79%, especially in the superior segment of

Fig. 5 A 3-year-old boy with cough and fever. a The initial chest radiograph shows well-defined, 4-cm left lower-lobe mass (arrows). b Chest radiograph obtained 4 weeks later reveals complete resolution

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Fig. 6 Loculated pleural fluid originally suspected to be round pneumonia in a 4-month-old boy. a Chest radiograph shows a welldefined round mass (arrows) abutting the right chest wall in the right

middle lobe and associated right upper lobe collapse and pleural effusion. b Chest CT scan obtained 1 week later reveals this lesion as a loculated pleural effusion (arrow) within the minor fissure

lower lobe. The predominant lower lobe distribution of lesions is thought to be related to bacteria-laden fluid initially passing by gravity into the most dependent bronchus and then to the periphery of the lung [2, 5]. The predominantly posterior distribution of lesions may also be related to the typically supine sleeping position of children [2]. In our study, the sizes of the round pneumonia lesions ranged from 1 to 12 cm and the mean diameter was 3.8 cm. These values are similar to previously reported dimensions [1113] of round pneumonia in adults, with sizes ranging from 1 to 7 cm and a mean diameter of 4 cm. Round pneumonia lesion margins were sharp in 70% and ill-defined in 30% of the children. The lesion margins have been reported in adults to be slightly ill-defined in 71% (10/14) [1113]. The lesion margin has been reported to be typically sharp in children [1]. In our series, the mean age of children with a sharp margin (5.3 years) was less than the age of those with an indistinct margin (6.8 years). The sharp lesion margin in younger children may be associated with the underdeveloped pores of Kohn and the absence of canals of Lambert [1]. The inflammation spreads in a centrifugal fashion and its advancing front is sharply demarcated from the unaffected lung parenchyma and causes a focal round mass to be seen on radiographs and CT scans [16]. Round pneumonia is seen less often and has ill-defined margins in children older than 8 years and in adults, who have fully developed collateral ventilation [2]. Follow-up chest radiographs were acquired in 39% of children (43/109), and 95% of these radiographs showed resolution (95%) and 4.6% showed progression to lobar pneumonia. This is consistent with previous reports [1114] that in the majority of patients round pneumonia eventually resolves clinically and radiographically with antibiotic therapy. Not only do round pneumonias tend to resolve,

but progression to lobar pneumonia prior to resolution is uncommon. In our series, three patients (2.6%) originally suspected to have round pneumonia were shown to have other diagnoses. The other diagnoses included cavitary necrosis in pneumonia in two patients and a focal collection of pleural effusion in the minor fissure in one. The two patients with cavitary necrosis were intensely ill and did not respond rapidly to antibiotic therapy. It is interesting that no diagnoses commonly discussed as being potentially confused with round pneumonia (bronchogenic cyst, pleuropulmonary blastoma, metastasis) were initially confused with round pneumonia in our series. In our series, CT was performed in seven children. In four of these, round pneumonia was seen on the superior images of abdominal CT scans performed to evaluate abdominal pain. Dedicated chest CT scans were performed in only three children (2.7%) with round pneumonia identified in this series. We do not advocate CT as a routine part of the evaluation of suspected round pneumonia. CT should be avoided when possible in children because of the associated radiation exposure and should be reserved for those in whom there is diagnostic uncertainty. If a child has a round opacity on radiography and has appropriate symptoms (cough, fever) of pneumonia, round pneumonia should be suspected and the child treated with antibiotics, and at most a follow-up chest radiograph should be obtained to ensure resolution of the rounded opacity.

Conclusion Round pneumonias occur in young children (mean age 5 years), tend to be a solitary lesion, and are most commonly

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Pediatr Radiol (2007) 37:12351240 7. Pandya K, Tuchschmidt J, Gordonson J et al (1989) Mass lesion in an intravenous drug user. Round pneumonia. West J Med 150:9596 8. Soubani AO, Epstein SK (1996) Life-threatening round pneumonia. Am J Emerg Med 14:189191 9. Wan YL, Kuo HP, Tsai YH et al (2004) Eight cases of severe acute respiratory syndrome presenting as round pneumonia. AJR 182:15671570 10. Shie P, Farukhi I, Hughes RS et al (2007) Round pneumonia mimicking pulmonary malignancy on F-18 FDG PET/CT. Clin Nucl Med 32:5556 11. Hershey CO, Panaro V (1988) Round pneumonia in adults. Arch Intern Med 148:11551157 12. Wagner AL, Szabunio M, Hazlett KS et al (1998) Radiologic manifestations of round pneumonia in adults. AJR 170:723726 13. Miyake H, Kaku A, Okino Y et al (1999) Clinical manifestations and chest radiographic and CT findings of round pneumonia in adults. Nippon Igaku Hoshasen Gakkai Zasshi 59:448451 14. Durning SJ, Sweet JM, Chambers SL (2003) Pulmonary mass in tachypneic, febrile adult. Chest 124:372375 15. Kohno N, Ikezoe J, Johkoh T et al (1993) Focal organizing pneumonia: CT appearance. Radiology 189:119123 16. Wang N (1998) Anatomy. In: Dail DH, Hammer SP (eds) Pulmonary pathology. Springer-Verlag, New York, pp 1740

located in the lower lobe and posterior area. Misdiagnosis of other pathology as round pneumonia is uncommon (2.6%).

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