Jpn J Radiol

DOI 10.1007/s11604-015-0420-7

ORIGINAL ARTICLE

Communityacquired pneumonia: a correlative study

betweenchest radiographic andHRCT findings
NobuyukiTanaka1,2 TakuyaEmoto3 HirokiSuda4 TsuneoMatsumoto5
NaofumiMatsunaga2

Received: 1 February 2015 / Accepted: 3 April 2015

Japan Radiological Society 2015

Abstract radiographic finding was evaluated by comparing it with

Purpose To elucidate what kinds of lesions tend to be the HRCT finding.
overlooked or misinterpreted and why they were over- Results The false negative rate of radiographic interpreta-
looked or misinterpreted on chest radiographs in the diag- tion tended to be higher for nodules and thickening of the
nosis of community-acquired pneumonia (CAP) by com- bronchial wall, especially in patients with atypical pneumo-
paring radiographic findings with HRCT findings. nia. The most frequent reason for false negative interpre-
Materials and methods In 129 patients with CAP (107 tations of nodules and bronchial wall thickening was the
bacterial and 22 atypical) and 105 healthy subjects, the overlapping of these findings with airspace consolidation
chest radiographic findings were correlated with the or ground-glass opacity (GGO). Thin lesions were the most
HRCT findings. The diagnostic accuracy of each chest frequent reasons for the false negative interpretation of air-
space consolidation and GGO.
Conclusion The chest radiographic interpretations of
GGO and airspace consolidation were influenced by the
* Nobuyuki Tanaka
ntanaka@yamaguchi.saiseikai.or.jp thickness of lesions, and those of nodules and thickening
of bronchial walls were influenced by coexisting GGO and
Takuya Emoto
temoto@tf6.sonet.ne.jp airspace consolidation and may contribute to a misinterpre-
tation of these lesions and an incorrect diagnosis of CAP.
Hiroki Suda
radiology@nagatohp.jp
Keywords Thorax CT-high resolution Lung
Tsuneo Matsumoto
matumoto@yamaguchihosp.jp Comparative study Infection
Naofumi Matsunaga
matsuna@yamaguchiu.ac.jp
Introduction
1
Department ofRadiology, Saiseikai Yamaguchi General
Hospital, 211 Midorimachi, Yamaguchi, Yamaguchi
The chest radiograph has been regarded as the method of
7538517, Japan
2
choice for the diagnosis of community-acquired pneumo-
Department ofRadiology, Yamaguchi University Graduate
nia (CAP). The reliability of chest radiographs, however, is
School ofMedicine, 111 Minamikogushi, Ube, Yamaguchi
7558505, Japan limited by the relatively lower detectability of lesions and
3 inter-observer variability in interpretation [1].
Department ofRadiology, Fukuoka Wajiro Hospital, 2275
Wajirogaoka Higashiku, Fukuoka, Fukuoka 8110213, Japan On the other hand, high-resolution CT (HRCT) has
4 been shown to be superior to chest radiographs in the diag-
Department ofRadiology, Nagato General Hospital,
85 Higashifukawa, Nagato, Yamaguchi 7594194, Japan nosis of diffuse infiltrative lung diseases (DILD) [2, 3]. It
5 has been used for the differential diagnosis of pneumonia
Department ofLaboratory Medicine, National Hospital
Organization, Yamaguchi-Ube Medical Center, among acute lung diseases. In addition, the differentiation
685 Higashikiwa, Ube, Yamaguchi 7550241, Japan of causative agents for pneumonia may also be needed in

13

order to determine the appropriate antibiotic therapy for
CAP patients [47].
Despite its superiority, CT should be used judiciously
because of the higher cost and the high radiation dose to
the thorax. The purpose of this study was to evaluate the
diagnostic capability of chest radiographs compared with
HRCT when used as a gold standard for CAP, which is
divided into bacterial and atypical pneumonia, and to deter-
mine what kinds of lesions tend to be overlooked or misin-
terpreted and why they were overlooked or misinterpreted
on chest radiographs. This will make it possible to deter-
mine the capability and limitations of chest radiographs, as
well as the appropriate indication for using HRCT in the
diagnosis of CAP.
Materials andmethods
Patients
Chest radiographs and HRCT scans obtained in 129
consecutive patients with CAP in one affiliated institu-
tion between April of 2002 and December of 2010 were
included in our study. Patients were identified through
a review of a CT database of outpatients who had under-
gone chest CT for suspected CAP. There were no criteria
as to whether CT should be done or not in that hospital. CT
examination was performed after a judgement and request
by the attending physician. Patients with CAP were further
divided into bacterial and atypical pneumonia cases. The
diagnosis of bacterial pneumonia was made by two pat-
terns; (1) a combination of laboratory examinations, includ-
ing an elevation of the white blood cell (WBC) count and
C-reactive protein (CRP), and positive results of sputum
culture, and (2) a combination of laboratory examinations,
including an elevation of the WBC count and CRP, and
immediate response using only penicillin or cephem anti-
biotics. A diagnosis of atypical pneumonia was made based
on a combination of laboratory examination, including an
elevation of CRP, and an elevation of the serum antibody
for Mycoplasma, Chlamydophila, or viruses. As a result,
107 patients with bacterial pneumonia and 22 patients
with atypical pneumonia (18 patients with Mycoplasma
pneumonia, 3 patients with Influenza viral pneumonia, and
one patient with Chlamydophila pneumonia) were identi-
fied. The cases with mixed infection of both bacterial and
atypical agents were excluded from this study. As a control
group, 105 consecutive healthy subjects were also included
who underwent chest radiograph and CT examination due
to a suspicion of lung cancer or tuberculosis after lung
cancer or tuberculosis screening tests, in which no abnor-
malities were found on CT. The patients with pneumonia
included 78 males and 51 females aged 1294years (mean
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Jpn J Radiol
age SD: 66.018.5years) and the control subjects
were 62 males and 43 females aged 2988years (mean
age SD: 5818.5years). There were 63 male and 44
female patients with bacterial pneumonia aged 2894years
(mean ageSD: 70.513.9years) and 15 males and 7
females with atypical pneumonia aged 1285years (mean
ageSD: 43.922.2years). There were no patients in an
immunosuppressive state in either group. The institutional
review board at this hospital did not require approval for a
retrospective study of routinely obtained clinical data and
radiological images.
Chest radiograph andCT scanning
The CT scans were obtained with an X-vision instrument
(Toshiba Medical Systems, Tokyo, Japan) at 120kV and
140mA. After contiguous 10-mm section CT was per-
formed through the chest, additional HRCT images con-
sisting of 2-mm section images were obtained at 2-, 5- or
10-mm intervals through the abnormal lung parenchyma
depicted on 10-mm section CT images. HRCT images were
reconstructed with a high-spatial-frequency algorithm.
CT scans were obtained at suspended end-inspiration, in
the supine position, without intravenous contrast material.
All images were viewed at window levels appropriate for
lung parenchyma (window width: 1500HU, window level:
600 HU) and mediastinum (window width: 300HU,
window level: 35HU). All 129 patients with pneumonia
underwent HRCT scans. The postero-anterior computed
radiograph images were obtained with an FCR XU-D1
instrument (Fujifilm Corporation, Tokyo, Japan) using
130kVp and 100mA with a photo-timer and a 12:1 grid.
The focus-object distance was 200cm. The mean interval
between chest radiograph and CT was 0.3days (range,
01days). All patients underwent a chest radiograph before
the chest CT examination.
Interpretation ofimages
The chest radiographs of all cases and HRCT scans of
patients with CAP were separately reviewed at 1-month
intervals by two chest radiologists and a final decision was
reached by consensus. The two observers had no knowl-
edge of the clinical information except that the subjects
were either patients with CAP or healthy subjects, so that
they could pay attention only to the presence or absence
of pneumonia shadows instead of making differential
diagnoses.
Each of the CT and radiographic findings was separately
coded as present or absent for the following: (1) airspace
consolidation, (2) ground-glass opacity (GGO), (3) nodules
and (4) thickening of the bronchial wall. Concerning HRCT
findings, consolidation was defined as marked increase in
Jpn J Radiol

lung attenuation with obscuration of underlying pulmo-
nary vessels. GGO was defined as a hazy increase in lung
attenuation without obscuration of underlying pulmonary
vessels. Nodule was defined as a rounded or irregular opac-
ity, well defined or poorly defined, measuring up to 3cm
in diameter. Concerning chest radiographic findings, con-
solidation was defined as marked homogeneous increased
lung opacification which completely obscures the margins
of vessels and airway walls and often contains air broncho-
gram within it. Ground-glass opacity was defined as hazy
increased lung opacification without air bronchogram
within which the margins of pulmonary vessels become
slightly indistinct. Nodules were defined as a rounded
opacity, well or poorly defined, measuring up to 3cm in
diameter [8]. The distribution of nodules in the interpreta-
tion of HRCT findings was recorded as centrilobular, peri-
lymphatic or random. Each HRCT finding was compared
between bacterial pneumonia and atypical pneumonia.
The most likely chest radiographic diagnosis of normal,
bacterial or atypical pneumonia was made on the basis of
previous chest radiographic descriptions of these diseases
in the literature [918], and the final decision was also
reached by consensus of the same radiologists. The diag-
nostic criteria of chest radiographs for bacterial pneumonia
include predominant airspace consolidation pattern, and
segmental, lobar or lobular distribution [913]; and those
for atypical pneumonia include bronchopneumonia pat-
tern or extensive or multifocal ground-glass opacification,
sometimes accompanied by bronchial wall thickening or
reticular opacities [1017].The distribution of pulmonary
disease was evaluated in six areas of the bilateral lungs as
follows. The upper zones were defined as the areas above
the level of the carina; the middle zones, between the level
of the carina and the level of the inferior pulmonary veins;
the lower zones, under the level of the inferior pulmonary
veins. All chest radiographic and HRCT findings were sep-
arately coded as present or absent in the six areas. When
more than two HRCT findings were present within one
lung area, all findings were recorded as present.
We hypothesized that the chest radiographic interpre-
tation of lesions, especially that concerning airspace con-
solidation and GGO, can be influenced by the thickness of
lesions detected and measured in the antero-posterior direc-
tion on HRCT images; therefore, we also measured the
maximum antero-posterior distance (thickness) of lesions
in order to correlate the interpretation of consolidation or
GGO with the thickness of the lesions. The interpretation
of lesions between the two modalities (patterns of HRCT/

Table1The HRCT findings and the accuracy of chest radiographic interpretation compared with each HRCT finding in all cases
HRCT findings Accuracy of chest radiographic interpretation
b
Positive (%) Negative (%) p value False negative (%) True positive (%) False positive (%) p valueb

Patients with CAP (N=129)a

Airspace consolidation 97 (75.2%) 32 (24.8%) 0.055 29 (22.5%) 90 (69.8%) 10 (7.8%) 0.007
Bacterial pneumonia (N=107) 84 (78.5%) 23 (21.5%) 27 (25.2%) 75 (70.1%) 5 (4.7%)c
Atypical pneumonia (N=22) 13 (59.1%) 9 (40.9%) 2 (9.1%) 15 (68.2%) 5 (22.7%)d
GGO 109 (84.5%) 20 (15.5%) 0.362 31 (24.0%) 82 (63.6%) 16 (12.4%) 0.132
Bacterial pneumonia (N=107) 89 (83.2%) 18 (16.8%) 24 (22.4%) 67 (62.6%) 16 (15.0%)
Atypical pneumonia (N=22) 20 (90.9%) 2 (9.1%) 7 (31.8%) 15 (68.2%) 0 (0%)
Nodules 69 (53.5%) 60 (46.5%) 0.047 51 (39.5%) 63 (48.8%) 15 (11.6%) 0.097
Bacterial pneumonia (N=107) 53 (49.5%) 54 (50.5%) 39 (36.4%) 53 (49.5%) 15 (14.0%)
Atypical pneumonia (N=22) 16 (72.7%) 6 (27.3%) 12 (54.5%) 10 (45.5%) 0 (0%)
Thickening of bronchial wall 79 (61.2%) 50 (38.8%) 0.463 48 (37.2%) 72 (55.8%) 9 (7.0%) 0.368
Bacterial pneumonia (N=107) 64 (59.8%) 43 (40.2%) 39 (36.5%) 59 (55.1%) 9 (8.4%)
Atypical pneumonia (N=22) 15 (68.2%) 7 (31.8%) 9 (40.9%) 13 (59.1%) 0 (0%)
Healthy subjects (N=105)
Airspace consolidation 102 (97.1%) 3 (2.9%)
GGO 99 (94.3%) 6 (5.7%)
Nodules 102 (97.1%) 3 (2.9%)
Thickening of bronchial wall 103 (98.1%) 2 (1.9%)
a
Community-acquired pneumonia
b
Chi-square test for independence or Fishers exact test between bacterial and atypical pneumonia
c
Significantly less frequent due to the result of adjusted standardized residuals in the chi-square test
d
Significantly more frequent due to the result of adjusted standardized residuals in the chi-square test

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Table2The sensitivity, specificity, and accuracy of chest radiographic interpretation compared with each HRCT finding in the six separate
areas
Right middle (%) Right middle (%) Right lower (%) Left upper (%) Left middle (%) Left lower (%)

Sensitivity
Consolidation
Bacterial pneumonia 73.3 50.0 71.2 77.8 62.5 71.4
Atypical pneumonia 100 60.0 60.0 100 100 83.3
All cases 75.0 51.2 70.2 80.0 67.9 73.2
GGO
Bacterial pneumonia 64.7 72.2 76.7 75.0 69.2 71.0
Atypical pneumonia 71.4 63.6 50.0 40.0 81.8 62.5
All cases 65.9 70.8 72.9 64.7 73.0 69.2
Nodule
Bacterial pneumonia 28.6 28.6 30.6 20.0 28.6 38.1
Atypical pneumonia 33.3 25.0 22.2 0 0 0
All cases 29.4 27.9 28. 16.7 23.1 26.7
Bronchial wall thickening
Bacterial pneumonia 20.0 32.5 51.3 37.5 35.3 54.5
Atypical pneumonia 16.7 12.5 40.0 50.0 20.0 25.0
All cases 19.4 29.2 50.0 40.0 31.8 50.0
Specificity
Consolidation
Healthy subject 100 98.1 98.1 100 100 99.0
Bacterial pneumonia 95.7 89.9 98.2 99.0 94.0 93.1
Atypical pneumonia 85.7 82.4 88.2 100 83.3 87.5
All cases 96.8 93.7 97.2 99.6 96.1 95.9
GGO
Healthy subject 100 99.0 97.1 99.0 98.1 97.1
Bacterial pneumonia 95.9 86.8 78.7 95.8 87.7 84.2
Atypical pneumonia 93.3 90.9 91.7 100 100 78.6
All cases 97.9 94.7 91.5 97.7 93.9 90.8
Nodule
Healthy subject 100 100 99.0 99.0 99.0 98.1
Bacterial pneumonia 96.2 88.9 88.7 97.9 93.0 88.4
Atypical pneumonia 100 92.9 100 100 100 100
All cases 98.5 95.3 95.2 98.6 96.6 94.1
Bronchial wall thickening
Healthy subject 100 100 99.0 100 100 99.0
Bacterial pneumonia 95.1 92.5 88.2 99.0 93.3 94.1
Atypical pneumonia 100 100 94.1 100 100 94.4
All cases 98.0 97.3 94.7 99.6 97.2 96.6
Accuracy
Consolidation
Healthy subject 100 98.1 98.1 100 100 99.0
Bacterial pneumonia 92.5 75.7 85.0 97.2 86.9 86.0
Atypical pneumonia 86.4 77.3 81.8 100 86.4 86.4
All cases 95.3 85.9 90.6 98.7 92.7 91.9
GGO
Healthy subject 100 99.0 97.1 99.0 98.1 97.1
Bacterial pneumonia 86.0 79.4 77.6 93.5 83.2 80.4
Atypical pneumonia 86.4 77.3 72.7 86.4 90.9 72.7

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Jpn J Radiol

Table2continued
Right middle (%) Right middle (%) Right lower (%) Left upper (%) Left middle (%) Left lower (%)
All cases 92.3 88.0 85.9 95.3 90.6 87.2
Nodule
Healthy subject 100 100 99.0 99.0 99.0 98.1
Bacterial pneumonia 78.5 69.2 69.2 90.7 80.4 78.5
Atypical pneumonia 81.8 68.2 68.2 90.9 77.3 59.1
All cases 88.5 82.9 82.5 94.4 88.5 85.5
Bronchial wall thickening
Healthy subject 100 100 99.0 100 100 99.0
Bacterial pneumonia 77.6 70.1 74.8 94.4 84.1 86.0
Atypical pneumonia 77.3 68.2 81.8 95.5 81.8 81.8
All cases 87.6 83.3 86.3 97.0 91.0 91.5

radiographic interpretation) was coded as follows: the
interpretation of airspace consolidation on HRCT seen
as normal, GGO, and consolidation on chest radiographs
was coded as Cons/Normal, Cons/GGO, and Cons/Cons,
respectively. In the same way, the interpretation of GGO on
HRCT seen as normal, GGO, and consolidation on chest
radiographs was coded as GGO/Normal, GGO/GGO, and
GGO/Cons, respectively. Some patients had consolidation
or GGO in more than two areas on HRCT; therefore, in
some cases there were more than two lesions of which the
thickness was measured.
Diagnostic capability ofchest radiograph inthe
diagnosis ofCAP
We calculated the sensitivity, specificity, accuracy, positive
predictive value, and negative predictive value for the chest
radiographic diagnosis, including healthy subjects, bacterial
pneumonia, or atypical pneumonia, by comparing with the
HRCT diagnosis as the gold standard. For each incorrect diag-
nosis, possible reasons were suggested by the two radiologists.
Statistical analysis

Correlation betweeneach chest radiographic andeach
HRCT finding
We evaluated the diagnostic accuracy of chest radiographs
of patients with pneumonia by defining the HRCT finding
as the gold standard. The interpretation of each chest radio-
graphic finding was divided into false negative (FN), true
diagnosis (TD), and false positive (FP) diagnosis based on
the HRCT findings as follows: (1) FN, abnormal lesions
depicted on HRCT images could not be detected as such
on chest radiograph, (2) TD, including true positive (TP),
all abnormal lesions on HRCT could be detected as such on
chest radiographs; and true negative (TN), all normal areas
on HRCT were interpreted as normal on chest radiograph,
(3) FP, normal areas on HRCT images were misinterpreted
as abnormal lesions.
We also evaluated chest radiographic interpretation
as TD, FP, and FN separately in the above-mentioned six
areas. In each radiographic finding of FN and FP, the rea-
sons for such misinterpretations were suggested by the two
radiologists based on their consensus. The reasons for chest
radiographic misinterpretation include lesional thickness.
In this respect, we defined thin or thick lesions as hav-
ing maximum antero-posterior distances less than 5cm or
more than 10cm, respectively.
The inter-observer agreement between the first two radiolo-
gists in the interpretation of each chest radiographic finding
was assessed by calculating the kappa value (-value). The
comparisons between the HRCT findings in the two types of
pneumonia were made using a chi-square test for independ-
ence. The comparisons of FP, TD, and FN of the chest radio-
graphic interpretations between the two types of pneumonia
were also made using a chi-square test for independence.
When the sample size was small, for example, a cell value
in the data table was less than 5, we used Fishers exact test
instead of a chi-square test. A p value <0.05 was considered to
indicate a significant difference. If a significant difference was
found between the groups using the chi-square test, adjusted
standardized residuals were calculated in order to clarify
which groups chest radiographic interpretation contributed to
the significant difference. An adjusted standardized residual of
>1.96 or <1.96 was considered to indicate significantly more
frequent or less frequent results, respectively. The correlation
between the interpretation of lesions (airspace consolidation
and GGO) and the thickness of lesions was assessed by Fish-
ers protected least significant difference (PLSD) test. A sig-
nificant correlation was considered present when the p value
was less than 0.05. These tests were performed using a com-
mercially available software program (SPSS Statistics, version
21 for Windows, IBM, Japan).

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Table3The suggested reasons for false negative and positive interpretations each finding in CAP cases
Pneumonia HRCT findings The suggested reasons

False negative interpretation

Pneumonia Bacterial Airspace consolidation (n=27) Thin lesion 19
cases Overlapping with the normal structure 8 (heart 3, diaphragm 3, others 2)
GGO (n=24) Thin lesion 15
Overlapping with normal structures 4 (heart 2, diaphragm 3)
Overlapping with airspace consolidation 4
Deep lesion (regarded as consolidation) 1
Nodules (n=39) Overlapping with consolidation or GGO 18
Small abnormality 15
Overlapping with normal structures 4 (heart 2, diaphragm 1, rib 1)
Misinterpretation as vessels 2
Thickening of bronchial wall Overlapping with consolidation or GGO 22
(n=39) Small abnormality 16
Overlapping with heart 1
Atypical Airspace consolidation (n=2) Thin lesion 1
Overlapping with the normal structure 1 (heart)
GGO (n=7) Thin lesion 5
Overlapping with normal structures 2 (heart 1, diaphragm 1)
Nodules (n=12) Overlapping with consolidation or GGO 8
Small abnormality 3
Overlapping with normal structures 1 (diaphragm 1)
Thickening of bronchial wall (n=9) Overlapping with consolidation or GGO 7
Small abnormality 2
False positive interpretation
Pneumonia Bacterial Airspace consolidation (n=5) Misinterpretation of thick GGO 3
cases Misinterpretation of normal structures 1 (pulmonary vessels)
Misinterpretation of nodules 1
GGO (n=16) Misinterpretation of thin consolidation 9
Misinterpretation of normal structures 1 (rib)
Misinterpretation of other abnormal 3 (linear opacity 1, nodules 2)
findings
Unidentified 3
Nodules (n=15) Misinterpretation of other abnormal 9 (consolidation 7, others 2)
findings
Misinterpretation of vessels 2
Unidentified 4
Thickening of the bronchial wall Misinterpretation of other abnormal 4 (consolidation 3, GGO 1)
(n=9) findings
Unidentified 5
Atypical Airspace consolidation (n=5) Misinterpretation of thick GGO 5
Healthy Airspace consolidation (n=3) Misinterpretation of normal structures 3 (pulmonary vessels 2 rib 1)
subjects GGO (n=6) Misinterpretation of normal structures 4 (pericardial fat 2, rib 1 vessels 1)
Unidentified 2
Nodules (n=3) Misinterpretation of vessels 2
Unidentified 1
Thickening of the bronchial wall Unidentified 2
(n=2)

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Jpn J Radiol
Results
Correlation ofchest radiographic interpretations
withHRCT findings
Concerning HRCT findings in patients with CAP (Table1),
nodules were significantly more frequently seen in patients
with atypical pneumonia than in those with bacterial pneu-
monia (p=0.047). Nodules were centrilobular in distribu-
tion and 10mm or less in diameter on HRCT images in
all cases. There was no significant difference in any of the
other HRCT findings between the two groups.
Concerning the accuracy of the radiographic interpre-
tation, the false negative rate was generally higher than
the false positive rate. The false negative rates of inter-
pretation of nodules and thickening of the bronchial
wall were high, and those of nodules and thickening of
bronchial wall in patients with atypical pneumonia was
especially high (54.5 and 40.9%, respectively) although
there were no significant differences in the frequencies of
false negative rates between bacterial and atypical pneu-
monia. There was a significant difference in the accuracy
of radiographic interpretation in airspace consolidation
between bacterial and atypical pneumonia (p =0.007).
The lower frequency of false positive rate (4.7%) in bac-
terial pneumonia and the higher frequency of false posi-
tive rates in atypical pneumonia contributed to the signifi-
cant difference.
Concerning the evaluation of chest radiographic inter-
pretation in the six lung areas, the results of sensitivity
were, in general, not so good, although those of specificity
and accuracy were relatively good (Table2). The sensitiv-
ity of nodules and bronchial wall thickening were generally
bad in all six lung areas. Concerning these two findings, the
sensitivity in atypical pneumonia tended to be inferior to
that in bacterial pneumonia. Especially, the sensitivity of
nodules in atypical pneumonia was 0% in the left lung.
The inter-observer agreement of chest radiographic
interpretation between the two radiologists was generally
good; the -values for airspace consolidation, GGO, nod-
ules and thickening of the bronchial wall were 0.83, 0.88,
0.66 and 0.68, respectively.
Reasons formisinterpretations ofchest radiographs
compared withHRCT findings
The suggested reasons for false negative and positive
interpretations of each finding are shown in Table3. Con-
cerning the reasons for a false negative interpretation of
airspace consolidation and GGO in both types of pneu-
monia, the presence of thin lesions in the antero-posterior
direction was the most frequent reason (Figs.1, 2). The
overlap with airspace consolidation or GGO was the most
frequent factor leading to a false negative interpretation of
nodules and thickening of the bronchial wall (Figs.3, 4).
These issues were more frequent in patients with atypical
pneumonia. Small abnormalities of lesions were the sec-
ond most frequent cause of false negative interpretations
of both nodules and thickening of the bronchial wall in
patients with both types of pneumonia.
Concerning the reasons for false positive interpreta-
tions of airspace consolidation and GGO, the misinterpre-
tation of airspace consolidation or GGO as the other was
most frequent due to the thickness of lesions. In particu-
lar, misinterpretations of GGO as airspace consolidation
were observed due to thick GGO in 5 patients with atypi-
cal pneumonia, which was associated with the significant
difference in the accuracy of radiographic interpretation in
airspace consolidation between bacterial and atypical pneu-
monia (p=0.007), described above. The misinterpretation
of other abnormal findings, including airspace consolida-
tion and GGO, was the most frequent reason for false posi-
tive interpretations of nodules and thickening of the bron-
chial wall.
Correlation ofchest radiographic interpretation
withthe thickening oflesions
The correlation of the difference between chest radio-
graphic and HRCT interpretations with the thickness of
the lesions is shown in Fig.5. The correlation between the
differences of both modalities and the thickness of lesions
was statistically significant. By using Fishers PLSD test,
we demonstrated that the measurement of the thickness of
lesions was significantly different between all the patterns
of HRCT and chest radiographic interpretation except for
between Cons/GGO and Cons/Normal. Therefore, the chest
radiographic interpretation was influenced by the thickness
of lesions (Figs.1, 2).
Diagnostic capability ofCAP bychest radiograph
Table 4 shows the overall diagnostic capability of chest
radiographs for detecting the presence or absence of pneu-
monia. The overall diagnostic capability of chest radio-
graphs for detecting both types of pneumonia was good for
all parameters. However, an accurate diagnosis of patients
with atypical pneumonia was made in only 6 out of the 22
patients.
The reasons for the incorrect chest radiographic diagno-
sis of pneumonia are shown in Table5. Seven patients with
bacterial pneumonia and 3 patients with atypical pneu-
monia were interpreted as normal. Overlooking nodules
and bronchial wall thickening due to small abnormalities
was the most frequent reason for this misdiagnosis in both
pneumonias. Overlooking of thin GGO was the second
13

Fig.1A 48-year-old male patient with bacterial pneumonia. The
chest radiograph of this patient was interpreted as bacterial pneumo-
nia. a High-resolution CT (HRCT) scan in the left lower lobe shows
focal airspace consolidation, the antero-posterior distance of which is
short. b Chest radiograph shows focal ground-glass opacification in
the left lower lung (arrows) which corresponds to airspace consolida-
tion on (a)
most frequent reason. However, there were no cases in
either type of pneumonia which were interpreted as nor-
mal on chest radiographs due to overlooked airspace con-
solidation. Twenty cases with bacterial pneumonia and 13
with atypical pneumonia were misinterpreted as atypical
and bacterial pneumonia, respectively. For about half of
the patients with either pneumonia, the reason for misdi-
agnosis was the resemblance of HRCT findings to those of
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Jpn J Radiol
Fig.2A 72-year-old male patient with bacterial pneumonia. The
chest radiograph of this patient was interpreted as atypical pneumo-
nia. a HRCT scan in the right lower lobe shows segmental consolida-
tion, the antero-posterior distance of which is short. b Chest radio-
graph shows ground-glass opacification in the central area of the right
lower lung which corresponds to airspace consolidation on (a)
the counterpart of either pneumonia. As to the reason for
the misdiagnosis of one pneumonia as the other, misinter-
pretation of consolidation or GGO as the other due to the
thickness of the lesion was frequent (Fig.2). Furthermore,
the most frequent reason for the misdiagnosis of atypical
pneumonia as bacterial pneumonia was overlapping of
nodules or bronchial wall thickening with consolidation or
GGO (Fig.4).
Jpn J Radiol
Fig.3A 43-year-old female patient with bacterial pneumonia. The Fig.4A 31-year-old female patient with atypical (mycoplasma)
chest radiograph of this patient was interpreted as bacterial pneumo-
nia. a HRCT scan in the right lower lobe shows focal segmental air-
space consolidation, around which tiny GGO nodules (arrows) and
thickening of the bronchial walls (arrow heads) are noted. b Chest
radiograph shows airspace consolidation in the right lower lung; how-
ever, it fails to show nodules or thickening of the bronchial walls
Discussion
In this study, the existence of thin lesions in the antero-
posterior direction was the most frequent reason for a
false negative interpretation of consolidation or GGO.
Also, considering the results of the correlation between
the radiographic interpretation and the thickness of the
lesions, consolidation or GGO may be underestimated
if the thickness of the lesion is thin. This result indi-
cated that consideration of the thickness of lesions in
the antero-posterior direction is important for the pre-
cise interpretation of consolidation and GGO, although
it is very difficult to recognize the thickness of lesions
pneumonia. The chest radiograph of this patient was interpreted
as bacterial pneumonia. a HRCT scan in the left upper lobe shows
segmental GGO, within which tiny GGO nodules (arrowheads) and
thickening of the bronchial walls (arrows) are seen. b Chest radio-
graph shows GGO in the left upper lung; however, it fails to show
nodules or thickening of the bronchial walls
on postero-anterior chest radiographs due to its inevitable
limitation.
As to the reasons for the false negative interpretation of
nodules and the thickening of the bronchial walls, the over-
lapping of nodules or thickening of the bronchial walls with
consolidation or GGO were the most frequent, especially
when the GGO or consolidation was conspicuous enough
to mask these lesions. We should re-recognize that chest
radiographs have an inevitable limitation due to the lack of
ability to differentiate superimposed opacities in the antero-
posterior direction [3]. Almost all reasons were due to the
technical disadvantages of chest radiographs, including
misinterpretation of lesional thickness and superimposed
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 Jpn J Radiol

Fig.5The correlation of the chest radiographic interpretation with and chest radiographic interpretation except for between Cons/GGO
the thickness of the lesions. The measurement of the thickness of and Cons/Normal by using Fishers PLSD test
pneumonic lesions was different between all the patterns of HRCT

Table4The accuracy of chest radiographic diagnosis in CAP and prominence of centrilobular nodules or the thickening of
normal cases the bronchial wall are the most important key HRCT find-
Chest radiographic diagnosis ings which discriminate atypical pneumonia from bacterial
CAP Healthy subjects
pneumonia [47, 16, 17, 20]. Also, in the current study,
nodules (centrilobular in distribution in all cases) were sig-
Bacterial Atypical nificantly more frequent in atypical pneumonia than bacte-
CAP (n=129) 119 10 rial pneumonia. However, there was no significant differ-
Bacterial (n=107) 80 20 7 ence in the frequency of bronchial wall thickening between
Atypical (n=22) 13 6 3 the two groups, the reason for which remains unknown. In
Healthy subjects (n=105) 9 96 the interpretations of radiographs, nodules and thickening
5 4 of the bronchial walls tended to be overlooked, especially
in patients with atypical pneumonia in almost all lung
Sensitivity: 92.2% (119/129), Specificity: 91.4% (96/105), accuracy: areas, although there was no statistically significant differ-
91.9% (215/234), positive predictive value (PPV): 93.0% (119/128),
negative predictive value (NPV): 90.6% (96/106)
ence between the interpretations. Reittner also mentioned
the difficulty in detecting lobular distribution, centrilobular
involvement, and interstitial abnormalities on chest radio-
opacities, except for 17 false positive interpretations we graphs, which could usually be detected on HRCT [17].
classified as unidentified. Concerning the lower sensitivity of nodules and bronchial
In clinical practice, it is essential to differentiate between wall thickening especially, the sensitivity of nodules in
bacterial and atypical pneumonia, and such classification is atypical pneumonia was 0% in all the left lung areas. The
one of the most important aspects described in the manage- reason for this remains uncertain because the influence of
ment guidelines for CAP published by the Japanese Res- cardiac silhouette makes it difficult to identify lower sensi-
piratory Society [19]. tivity in all the left lung areas.
Therefore, the differential diagnosis based on radio- Furthermore, the overlooking of nodules or thickening
logic findings is essential. Although there have been few of the bronchial wall was indicated as a possible explana-
reports of HRCT findings in patients with atypical pneumo- tion for the misdiagnosis of both types of pneumonia as
nia other than mycoplasma pneumonia, it is likely that the normal. On the other hand, the overlooking of airspace

13
Jpn J Radiol

Table5The reasons for the incorrect diagnosis of pneumonia

Incorrect diagnosis Reasons for false negative diagnosis

Bacterial pneumonia (Total 107 cases) Atypical pneumonia (n=20) Resemblance of HRCT findings to atypical pneumonia 11
Misinterpretation of consolidation as GGO due to the thin 9
consolidation
Normal (n=7) Overlooking of nodules or bronchial wall thickening due to small 7
abnormalities
Overlooking of GGO due to the thin lesion 3
Overlooking of GGO hidden behind the diaphragm 1
Atypical pneumonia (Total 22 cases) Bacterial pneumonia (n=13) Overlapping of nodules or bronchial wall thickening with 7
consolidation or GGO
Resemblance of HRCT findings to bacterial pneumonia 6
Misinterpretation of GGO as consolidation due to the thick GGO 2
Normal (n=3) Overlooking of nodules or bronchial wall thickening due to small 2
abnormalities
Overlooking of GGO due to the thin lesion 1
Overlooking of GGO hidden behind the diaphragm 1
Overlooking of nodules or bronchial wall thickening hidden behind 1
the diaphragm
Healthy subjects (Total 105 cases) Bacterial pneumonia (n=5) Misinterpretation of normal structure as consolidation 3
Misinterpretation of normal structure as GGO 2
Misinterpretation of normal structure as nodules 1
Atypical pneumonia (n=4) Misinterpretation of normal structure as GGO 2
Misinterpretation of normal structure as nodules or bronchial wall 2
thickening

There were some cases with multiple reasons for false negative diagnosis

consolidation did not contribute to the reasons for a missed
diagnosis of pneumonia. This result shows that lobar pneu-
monia, which is supposed to be more frequent in bacterial
pneumonia rather than in atypical pneumonia [4], could
confidently be detected by chest radiograph, since this type
of pneumonia usually shows extensive airspace consolida-
tion by the time patients show clinical symptoms. It also
indicates that a correct radiographic diagnosis of atypical
pneumonia may sometimes be impossible due to the dif-
ficulty in detecting nodules or thickening of the bronchial
wall when consolidation or GGO is predominant. This is
the most frequent reason for the misdiagnosis of atypical
pneumonia as bacterial pneumonia. Although the misin-
terpretation of thick GGO as airspace consolidation was
observed in 5 patients with atypical pneumonia, only 2
patients were misdiagnosed as having bacterial pneumonia.
In this study, the accurate diagnosis of atypical pneumonia
was made in only 6 of the 22 cases. It might be related to
the technical disadvantages derived from chest radiographs
due to their inability to enable differentiation of superim-
posed opacities. Therefore, HRCT could be indicated if the
radiographic features do not match those of atypical pneu-
monia although atypical pneumonia is clinically suspected.
As to the diagnostic capability of chest radiographs
for CAP, by combining bacterial and atypical pneumonia
together, the sensitivity, specificity, accuracy, PPV, and
NPV were generally good, in spite of the difficulty in dif-
ferentiating between bacterial and atypical pneumonia. The
inter-observer agreement of chest radiographic interpreta-
tion between the two radiologists was also good. The rea-
son for these two good results is partially because the two
chest radiologists had known that patients were all either
normal subjects or patients with pneumonia. Because other
pathologies or circumstances would likely complicate the
diagnosis in actual clinical practice, the overall diagnostic
accuracy of a chest radiograph would likely be lower.
There were several limitations in this study. First, the
number of atypical pneumonia cases is smaller than that
of bacterial pneumonia, which may be associated with
the larger number of elderly patients. Therefore, it might
not be possible to draw solid conclusions about the differ-
ences in the detectability of pneumonia between the two
types of pneumonia. Another weakness of this study is its
retrospective design. It is difficult to perform a prospective
study of pneumonia since it is difficult to perform CT in all
cases which are suspected of having pneumonia from the
viewpoint of radiation exposure. Furthermore, concerning
the chest radiographic interpretation of consolidation and
GGO, the differentiation between the two findings is often
difficult, even though two chest radiographic findings were
defined in this study. This might affect the results of corre-
lation between chest radiographic and HRCT findings, and

13

in addition, the diagnostic capability of chest radiographs.
Finally, there might be a selection bias in the process of
choosing pneumonia patients because only those patients
who had uncertain radiographic findings underwent chest
CT. Therefore, it might be difficult to generalize the diag-
nostic capability of chest radiographic diagnosis for CAP
in this study.
Conclusion
The chest radiographic interpretations of GGO and con-
solidation were influenced by the thickness of lesions, and
those of nodules and thickening of bronchial walls were
influenced by coexisting GGO and consolidation. As to the
causes of incorrect diagnosis of pneumonia by chest radio-
graph, the overlooking of centrilobular nodules and the
thickening of bronchial walls occurred frequently. There-
fore, the diagnostic capability of chest radiographs seems a
little inferior in atypical pneumonia to bacterial pneumonia,
although the sensitivity, specificity, and accuracy of chest
radiographic diagnosis were generally good.
Acknowledgments This research received no specific grant from
any funding agency in the public, commercial, or not-for-profit sec-
tors. The authors are grateful to Steven Gardner for the preparation of
the English manuscript.
Conflict of interest The authors declare that they have no conflict
of interest and there is no ethical problem.
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