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. Persistence is attributed to defects in host immune defense mechanisms, presence of unusual or resistant organisms, or diseases that mimic pneumonia.
The classification of these disorders may become quite complex, as some clinicians focus primarily on the radiologic abnormalities, while others emphasize the accompanying clinical features. Nonresolving or slowly resolving pneumonia is loosely defined as a 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. Slowly resolving pneumonias are usually defined as the persistence of radiographic infiltrate in a clinically improved patient for longer than 4 weeks (<50% resolution in 1 month).
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. Nonresponding pneumonia is an inadequate clinical response despite antibiotic treatment. It is an independent risk factor for death and delayed resolution of pulmonary infiltrate. Noninfectious causes are responsible for about 20% of cases of nonresolving pneumonia.
A good clinical response to pulmonary infiltrate is defined as 50% clearing of chest radiographic findings at 4 weeks of therapy. Clinical improvement and resolution of leukocytosis supports the conclusion that the patient has responded to antibiotic therapy, even when chest radiographic abnormalities persist. 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 radiographs are unchanged or worse, or if at least partial radiographic resolution is lacking by 4 weeks, further evaluation is essential, even in asymptomatic patients. This is the case for pneumonia, but persistent pulmonary infiltrates may result from other reasons (e.g., pulmonary edema).
Resolution of nonresolving pneumonias varies and depends on the causal agent, the severity of disease, and host factors. Several risk factors may hinder the rate of radiographic clearing of the condition:
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
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
Initial severity of the infection
Delay in initiation of therapy.
- Community-acquired pneumonia (nonresolving)
- Atypical pneumonia (nonresolving)
- Hospital-acquired pneumonia (nonresolving)
- Lung abscess
- Lung cancer (metastatic)
- Small cell lung cancer
- Non-small cell lung cancer
- Aspiration pneumonia
- HIV (AIDS)
- Pneumocystis jiroveci pneumonia (nonresolving)
- Pulmonary embolism
- Cardiogenic pulmonary edema
- Foreign body aspiration
- Interstitial lung disease
- Organizing pneumonia
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Sjogren syndrome
- Lymphoma and acute leukemia
- Kaposi sarcoma
- Diffuse alveolar hemorrhage
- Systemic vasculitis
- Granulomatosis with polyangiitis (formerly known as Wegener granulomatosis)
- Churg-Strauss syndrome
- Allergic bronchopneumonic aspergillosis
- Loeffler syndrome
- Hypersensitivity pneumonia (extrinsic allergic alveolitis)
- Acute idiopathic eosinophilic pneumonia
- Idiopathic chronic eosinophilic pneumonia
- Drug-induced infiltrate
- Cocaine abuse
- Radiation pneumonitis
- Langerhans cell histiocytosis
- Lipoid pneumonia
- Pulmonary alveolar proteinosis
Athanasia Pataka, MD
AP declares that she has no competing interests.
Dr Athanasia Pataka would like to gratefully acknowledge Dr Paraskevi Argyropoulou-Pataka, a previous contributor to this topic.
PAP declares that she has no competing interests.
Cristine Radojicic, MD
CR declares that she has no competing interests.
Mathina Darmalingam, MBChB, FCP
Clinical Lead in Respiratory Medicine
Whipps Cross University Hospital
MD declares that she has no competing interests.
Ioannis P. Kioumis, MD, PhD
Pulmonary Medicine and Infectious Diseases
Pulmonary Medicine Clinic
IPK declares that he has no competing interests.
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