Persistent pulmonary infiltrate results when a substance denser than air (e.g., pus, edema, blood, surfactant, protein, or cells) lingers within the lung parenchyma. Nonresolving and slowly resolving pneumonias are the most common broad categories of persistent pulmonary infiltrate.[1] [2] [3] Persistence is attributed to defects in host immune defense mechanisms, presence of unusual or resistant organisms, or diseases that mimic pneumonia.[4] [5]
Summary
Classification
The classification of these disorders may become quite complex, as some clinicians focus primarily on radiologic abnormalities, while others emphasize accompanying clinical features. Nonresolving or slowly resolving pneumonia is loosely defined as pneumonia that does not improve clinically, or even worsens, despite a minimum of 10 days of adequate antibiotic therapy or as radiographic infiltrate that does not resolve within 12 weeks.[6] [7] Slowly resolving pneumonia is usually defined as the persistence of radiographic infiltrate in a clinically improved patient for >4 weeks (<50% resolution in 1 month).[8] [9] [10] [11]
A waiting period of 12 to 14 weeks is suggested for slowly resolving pneumonia to be considered nonresolving (or chronic) in older patients with nontuberculous bacterial pneumonia.[6] Nonresponding pneumonia is characterized by inadequate clinical response despite antibiotic treatment. It is an independent risk factor for death and delayed resolution of pulmonary infiltrate.[12] [13] Noninfectious causes are responsible for about 20% of cases of nonresolving pneumonia.[12]
Therapeutic response
A good clinical response to pulmonary infiltrate is defined as a 50% clearing of chest radiographic findings at 4 weeks of therapy.[6] Clinical improvement and resolution of leukocytosis support the conclusion that the patient has responded to antibiotic therapy, even when chest radiographic abnormalities persist.[2] Most patients have a normal temperature and decreased cough within 3 to 5 days after beginning treatment. When clinical improvement has not occurred and chest radiographic findings are unchanged or worse, or if at least partial radiographic resolution is lacking by 4 weeks, further evaluation is essential, even in asymptomatic patients.[2] [10] [14] This is the case for pneumonia, but persistent pulmonary infiltrates may result from other reasons (e.g., pulmonary edema).
Variant response
Resolution of nonresolving pneumonia varies and depends on the causal agent, the severity of disease, and host factors.[4] [6] Several risk factors may hinder the rate of radiographic clearing of the condition:[2][15]
- Age over 60 years: radiographic clearance of pneumonic infiltrate on completion of antibiotic therapy decreases by 20% per decade after the age of 20 years
- Malnutrition
- Comorbid conditions (COPD, cardiac failure, diabetes, renal failure, immunodeficiency, alcohol intake, smoking, occupational exposure, cancer, cancer treatment, systemic illness): patients with hematologic malignancies; immunosuppressive disorders; or exposure to silica, aluminum, or titanium dust are prone to persistent pulmonary infiltrate
- Causal microorganism
- Initial severity of the infection
- Delay in initiation of therapy.
Last updated
Library
Causes of nonresolving pneumonia
Posterior-anterior chest x-ray in Pneumocystis jiroveci pneumonia showing severe, bilateral pulmonary interstitial infiltrates with pneumatoceles
Causes of persistent pulmonary infiltrate in immunocompromised patients
Etiologies and possible differential diagnosis of interstitial lung disease
Posterior-anterior chest x-ray with bibasilar linear interstitial changes consistent with asbestosis
Chest x-ray of a patient with eosinophilic pneumonia
Chest CT scan of a patient with amiodarone pulmonary toxicity showing asymmetric opacities with a peripheral distribution
Chest x-ray of a patient with amiodarone pulmonary toxicity
Possible causal agents of drug-induced pulmonary parenchymal disease
Radiographic resolution of causal pathogens of pneumonia
Citations
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