大햄}jj( íl、u흉뽑횡용註‘ 第 24 卷 第 3 號 pp. 477 - 484, 1988 Journal of Korean Radiological Society, 24(3) 477-484, 1988

Radiologico-pathologic Correlation of the

Pulmonary Disease in the Autopsied Infants

Young Seok Lee, M.D. , Dae Chul Suh, M.D.' , Sung Sik Lee , M.D. **

Soon 11 Lee, M.D. " , Je Geun Chi , M.D.

D epartment o f R adiology , S o wha Children ’'s Hospital

〈국문초록〉

부검을 시행한 신생아에 있어서 폐질환의 방사선학적 병리학적 고찰

소화아동병 원 방사선과

이영석 • 서대철 이성식 이순일 지제근 •••

1 984년 11월 부터 1986년 3월 까지 소화아동뱅원 신생아 집중치료실에서 사망하여 서울대학교 의파대

학 뱅러학교살에서 부검을 시행한 62영의 폐 질환에 대한 방사션학석 ， 영리학석 고찰을 하여 마음과 같

은 결론을 얻었마.

1. 총 62명의 신생아중 미 숙아 33예 (53 . 2%) ， 저출생체중아 44예 ( 7 1. 0%)였다.

2. 발생 반도에 따른 폐질환의 분포는 페램이 33예 (53% )로 가장 않았A여 그외 유리질막질환 1 7예

(27 % ) , 폐영변이 없는 경우 9예 ( 15% ), 폐 형성부선증이 3예 (5%) ， 폐 출혈이 1예 ( 2 %)였 마.

3. 양수흡인성 퍼l 령의 50% , 선천성 폐령의 77. 8% , 후천성 폐령의 88. 9% , 유리 질악질환의 88 . 2 %에

서 방사선학척 소견이 병리 학적 소견과 일치 하였다.

4. 선천성 폐 렴 9예 의 방사선학적 소견은 폐 문주위 칭 윤을 보인 경 우가 4여1. 미 만성 파립 성 • 앙상결절

성 첨윤이 3예 ， 페 침윤이 보이지 않는 경우가 2예였마.

Introduction pulmonary hemorrhage are also most frequently encountered 1-2) .

It has been known that the major causes of The authors analyzed radiological and patholo-

death in infancy are many conditions originating in gical findings of perinatal pulmonary disease trying

perinatal period. Pulmonary disease is the most to elucidate radiological clues for the diagnosis , common cause of morbidity and mortality in the treatment and prognosis of pulmonary diseases in

newbron infant. Pathologically , hyaline membrane the newborn infants.

disease , fetal aspiration syndrome , pneumonia and

• 중앙걸뱅원 방사선파 • Department o[ R adiology, Chung Ang Gil General

Hospi tal •• 소화 아동병 원 소아파 • Department o[ Pedia trics, Sowha Children ’'s Hos.

pital … 서울대학교 의파대 학 뱅 리학교실 .. Department o[ Pathology, S eo ul National Universi ty

Children ’s Hospital 이 논문은 1988년 4월 30일에 캡 수하여 1 988년 6월 24 일에 채택되었음

Materials and Methods

The materials for this study were sixty two in­

fants who expired in Neonatal Intensive Care Unit

at Sowha Children’s Hospital from Nov. 1984 to

Mar, 1986. The postmortem examinations were

performed at department of pathology, Seoul

National University Children ’s Hospital.

We retrospectively reviewed radiologic and

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1988 -第 3 號第 24 卷- 大韓放射線醫學會註 :

Gestational Age and Birth Weight Distribution of Autopsied Infants Table 1.

만쁘Weight(gm )

Gestational Age(wks) Total

?l

qι 。ι

nU

5

8

7

2

---i

qι

2,500 <

o o n l

1,500-2 ,500

8

얘 8

1

< 1,500

-32

32-37 37-42 42-

62 18 33 11 Total

Distribution of Pulmonary Disease Table 2. pathologic findings of lungs in sixty two autopsied

intants. We also evaluated distribution and pat­

terns of p비monary diseases and the radio­

logico-pathologic correlation. M

9

9

N。

32

n 3

1

9

Pneumonia Aspiration Congenital Acquired

Hyaline Membrane Disease Pulmonary Hypoplasia Pulmonary Hemorrhage No pulmonary Lesion

Diseases

62

nia . The amniotic fluid aspiration pneumonia was

associated with 5 cases of meconium and hemorr­

hage, 4 of meconium , 2 of meconium and bron­

chopneumonia and one case of broncho­

pneumonia(Fig. 1) .

Findings of chest roentgenograms were diagnos­

tic for only in 7 cases among all amniotic fluid

aspiration penumonia. The other half showed nor­

mal findings in 5 cases and hyperinflation without

p비monic infiltrations in 2 cases(Table 3) .

Total

There were 33 cases(53 .2%) of prematurity

among the sixty two infants and 44 cases(71.1 % )

of low birth weight including 11 cases of the very

low birth weight less than 1,500 gm(Table 1) . The

male to female ratio was l.3: l.

The pu!monary diseases were confirmed patho­

logically through complete postmortem examina­

tion. They consisted of 33 cases of pneumonia, 17

of hyaline membrane diseases , 3 of pulmonary

hypoplasia , one of pulmonary hemorrhage and 9

of no demonstrable pulmonic lesions(Table 2)

Pneumonia was the most common pulmonary dis­

ease in the autopsied infants.

Among 33 cases of pneumonia, there were 14

cases of amniotic fluid aspiration pneumonia , 9 of

congenital pneumonia and 9 of acquired pneumo-

Results

Radiologico-Pathologic Correlation of Amniotic Fluid Aspiration Pneumonia Table 3.

Chest Roentgenogram Diagnostic Not diagnostic

Total

N 0 Associate Lesion c Meconium c Meconium & Hemorrhage c Meconium & Bronchopneumonia c Bronchopneumonia

?ι A*

FD

9“ 14

2

4

1

?‘ ?“ 1i

14

1i

Pathological Diagnosis

14

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7 7 Total

- Y oung Seok Lee , et al.: Radiologico-patholog ic Correlat ion oÍ the Pulmonary .. -

A

Fig. 1. Amniotic fluid aspiration pneumonia and su­perimposed bacterial pneumonia

A. Non-uniform , coarse infiltrations and hyperinflati on of the lung on the first day 。f life

B. Progressive hyperinflation and patchy in­filtrations of the lung on the seventh day of life

C. Gross specimen of the lung Cut surface of the right and left lungs show diffuse and patchy di scoloration in the background of pulmonary congestion

Fig. 2. 2 Cases of congenital pneumonia A. P erihilar streaky infiltrations of both lungs

and decreased thymic shadow B. Diffuse granul ar densities of both lungs

and prominent thymic shadow C. Microscopic picture showing interstitial

thickening and small round cell infiltration The alveolar spaces are re latively pre­served

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A

B

C

- 大韓放射線醫學會誌 : 第 24 卷 第 3 號 1988

Radiological findings of congenital pneumonia

(9 cases) presented perihilar streakl) , diffuse

granular or reticulonodular3) and no demonstrable

p비monic infiltrations2). In addition , thymic sha­

dows were invisible or decreased in 8 cases and

prominent in one case on the chest roentgeno­

grams(Table 4)(Fig. 2).

Nine cases of acquired pneumonia consisted of 6

cases of bronchopneumonia associated with

hemorrhage2) , and 3 cases of pneumocystis carinii

pneumonia with 2 of cytomegalic inclusion dis­

eases(Fig. 3) and one candidiasis. One case of

pneumocystis carinii pneumonia showed atypical

findings of pneumatocele. There were radiologi­

co-pathologic good correlations with 8 cases of

acquired pneumonia except only one case of nor­

mal chest roentgenographic finding(Table 3).

In pathological patterns of 17 cases of hyaline

membrans diseases , 11 cases were associated with

another lesions such as hemorrhage4) , pneumonia2

),

Table 4. Radiologic Findings of 9 Cases of Congenit. al Pneumonia

Findings N。

Pulmonary Infiltration Perihilar Streaky 4 Diffuse Granular or Reticulonodular 3 No Lesion 2

Thymic Shadow Invisible or Decreased 8 Prominent

A

B

Fig. 3. Pneumocystitis cann l1 pneumonia and super. imposed cytomegalic inclusion disease A. Dìffuse interstitial infiltrations of the lung

with hyperinflation of right upper lung B. Microscopic findiilgs of the lungs. the

alveoli are filled with finely granular and foamy material There are also interstitial plasma cell infil­tration and a focus of cytomegalic inclu. sion.in a pneumonocyte in the center of the field

Table 5. Radiologico-Pathologic Correlation of Acquired Pneumonia

Pathological Diagnosis Diagnostic Not Diagnostic

Chest Roentgenogram Total

Bronchopneumonia N 0 Associated Lesion c Hemorrhage

Pneumocystis Carinii c Cytomegalic Inclusion Disease c Candidiasis

6

3 2

4·?ι

q니

2 2

Total 9 8

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A

B

- Y oung Seok Lee , et al.: Radiologico'pathologic Correlation 01 the Pulmonary" 'I-

hemorrhage and pneumonia3l(Fig. 4) , hemorrhage

and bronchopulmorary dysplåsia ll(Fig . 5) and

meconium aspiration1l, six cases were not associ­

ated with other lesions.

The findings of chest roentgenogram was di­

agnostic for hyaline membrane diseases and its

associated lesions in 15 cases. Two cases of hyaline

membrane diseases showed normal finding and

patchy infiltrations on chest roentgenogram re­

spectively(Table 6) .

Distribution of misceIlaneous cases was one case

of pulmonary hemorrhage and 3 cases of p비mon­

ary hypoplasia related to two of Potter’s syn­

dromes and one of 18 trisomy.

Discussion

Mortality rate of newborn and neonate has been

decreased by the development of neonatology and

other supporting systems. Nevertheless, respira-

C

Fig. 4. Hyaline membrane disease associated with pulmonary hemorrhage & bronchopneumonia A. Diffuse fine granular densities and ai r bronhograms of both lungs B. Homogeneous consolidations in both lower lungs with air bronchograms C. Gross specimen of the lungs. the posterior aspects of both lungs show di ffus딩 consolidation, glistening

pleura and ectatic lymphatics D. Photomicroscograph of the lung, showing a thick homogeneous glassy membrane(hyaline membrane)

lining in a dilated alveolar duct The alveoli are collapsed

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D

- 大韓放射線훌훌學會誌 : 第 24 卷 第 3 號 1988 -

A

B

C

Fig. 5. Hyaline membrane disease associated with bronchopulmonary dysplasia A. Diffuse granular densities and fine air

bronchograms of both lungs on the third day of life

B. Irregular linear increased densities and un­even aeration of the lungs on the twenty day of life

c. Photomicrograph of the lung, showing obliterated alveolar spaces and replace­ment of fibrous connective tissue. Focal proliferation of alveolar penumonocytes is also note

tory disorders have been the major causes of mor­

tality and morbidity in infancy until now.

According to Schaffer’s report3) , pulmonary in­

flammation of some degree was found in 27(35%)

of 76 autopsies on stillborn and newborn infants ,

was considered a contributory cause of death in

7(9%) , and was the sole causε of death in 6(8%).

In our series, pneumonia also was the most

common cause of the p비monary diseases in the

autosied infants . Florman et a14) observed en­

hancement of bacterial growth in amniotic fluid by

meconium and they suggested that the fetus who

remained in meconium stained amniotic fluid

might be exposed to far greater numbers of bac­

teria than one whose amniotic fluid does not con­

tam mecomum _

According to previous reports , radi이ogical fea­

tures of meconium aspiration pneumonia consisted

of non-uniform , coarse , patchy infiltrates radiating

from hilum :ïnto the peripheral lung fields and une­

ven aeration of the lung2,5,6). 50% of amniotic and

mecomum asplrahon pneumonía m our senes were

compatible with the radiologic features. Gooding

and Gregory7) found that 60 per cent of the infants

born through meconium stained amniotic fluid had

normal chest roentgenograms. 35.7% of all amnio­

tic aspiration pneumonia in our series showed nor­

mal chest roentgenograms.

Diffuse , though not necessarily uniform , in­

flammation has been the prominent pattern associ­

ated with congenital pneumonia. The inflamma­

tory infiltrate was largely of lymphocytes , plasma

cells and neutrophils almost in equal composition , and its distribution was more interstitial than

alveolar. Although there were some exudates in

the alveoli they were mostly cellular and fibrin

exudation was minimaL In most of the cases prem­

ature rupture of membrane was noted in the his­

tory of the mothers.

The inflammatory cell reaction has been vari­

ably described as acute , mononuclear and intersti­

tial but diffl.lse pne l.lmonia in the peripheral por-

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- Young Seok Lee , et al.: Radiologico'pathologic Correlation of the Pulmonary ... -

Table 6. Radiologico'Pathologic Correlation of Hyaline Membrane Disease

Pathological Diagnosis Diagnostic Not diagnostic

Chest Roentgenogram Total

No Associated Lesion c Hemorrhage c Pneumonia c Hemorrhage & Pneumonia c Hemorrhage & Bronchopulmonary

Dysplasia c Meconium Aspiration

ζU A%

1i

。J

ζU A*

ηι 。、υ

Total 2 15 17

tion of the lung has been conversely taken as

characteristic of antenatal infection용11) The au­

thors reviewed radiological findings of pathologi­

cally proven congenital penumonia. 77.8% of con­

genital pneumonia showed characteristic patterns

of interstitial pneumonia which were consistent

with pathológical findings. The other 22.2 per cent

showed normal chest roentgenograms probably

due to being masked interstitial densities by over­

aeration of the lung.

Diagnostic accuracy of chest roentgenograms

was 88.9% for 뽕quired pneumonia in this series.

One case of pneumnocystis carir피 pneumonia

showed penumatocele, one of unusual manifesta­

tions including pleural effusion , empyema, pneumothorax, pneumomediastinum, lobar con­

solidation and nodular densities12).

The name “ hyaline membrane disease" is de­

rived from the histopathologic findings. At necrop­

sy , the lung are of uniform dark purple color and

sink when placed in water. Microscopically the

alveoli are a characteristically atelectatic, and the

frequently overdistended alveolar ducts are lined

with rather amorphous eosinophilic materials13 ,14).

The radiologic patterns of hyaline membrane dis­

ease can be described as finely granular or even

reticulonodular densities and air bronchograms ex­

tending far peripherally into the lung. 88.2 per cent

of the author ’s cases showed the characteristic

findings for hyaline membrane disease.

Ellis et a114) reported that acquired pulmonary

disease other than hyaline membrane disease such

as hemorrhage, pneumonia, atelectasis, or aspira­

tion of amniotic fluid , singly or in comtination , was a major finding at necropsy. The authors also

experienced hyaline membrane disease associated

with hemórrhage , pneumonia , bronchopulmonaπ dysplasia and aspiration of meconium.

Summary

Authors retrospectively analysed chest roent­

genographic and pathologic findings of the sixty

two autQpsied infants under the clinical informa­

tions. We also evaluated distribution and patterns

of P비monary diseases and the radiologicc• patho­

logic correlation. The results were as follow:

1. There were 33 cases(53.2%) of prematurity

among Sixty-two infants and 44 cases(71.0%) of

low birth weight.

2. The distribution of the pulmonary diseases , in

order of frequency , was 33 cases(53%) of pneumo­

nia , 17(27%) of hyaline membrane diseases , 9(15% ) of no demonstrable pulmonic lesion, 3(5%) of pulmonary hypoplasia and 1(2%) of pul­

monary hemorrhage.

3. The radiological findings were consistent with

the pathological findings in 50% of amniotic fluid

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- 大韓放射線훌훌學會誌 : 第 24 卷 第 3 號 1988 -

aspiration pneumonia 88 .9% of acquired and 88.2

% of hyaline membrane diseases.

4. Radiological findings of 9 cases of congenital

pneumonia were perihilar streaky infiltrations in 4

cases, diffuse granular or reticulonodular infiltra­

tions in 3 cases , and no demonstrable pulmonic

infiltrations in 2 cases .

REFERENCES

l. Hoffman RR , Campbell RE , Decker ]P: Fetal

Aspiration syndrome Clinical, roentgenologic and

pathologic features. A]R 122(1): 90 , 96, 1974

2. Peterson HG , pendleton ME: Contrasting Roentge.

nographic pulmonary patterns of the hyaline mem­

brane and fetal Aspiration syndrome. A]R

74(5):800-817, 1955

3. Schaffer AJ, Markowitz M, Perlman A: Pneumonia

in Newborn Infants. ].A. M. A. 159(η 663-668, 1955

4. Florman AL , Teubner D: Enhancement of Bacterial

Growth in amniotic fluid by Meconium. ]. Pediatr

74(1): 111 -114, 1969

5. Bacsik RD: Meconium Aspiration syndrome Pedia-

tric Clinics of North America 24(3): 463-079, 1977

6 이영석， 이 성식， 이홍규 둥 : 신생아에 있어서 태변

흉안층의 방사선학적 고창. 대한방사선의학회지 21

(1): 76-83, 1985

7. Gooding CA , Gregory GA: Roentgenographic analy­

sis of meconium Aspiration. Radiology 100:131 ,

1971

8. Bernstein ] , Wang ]: Thepathology of Neonatal

pneumonia. Am ] dis of child 101:104-116, 1961

9. Adams ]M ‘ Congenital pneumonitis in Newborn

infants Am ] dis of child 75:544-554, 1948

10. Anderson GS , Green CA , Neligon BA et al: Con­

genital Bacterial Pneumonia. Lan cet 2:585-587,

1962

11 이성식， 이 순일， 이영석 둥 : 선천성 폐램에 대한 임

상. 영리학적 고찰. 소아과 29(6) : 653-660, 1986

12. Luddy RE , Champion LA , Schwartz AD et al

Pneumocystitis carinii pneumonia with pn euma­

tocele formation. Am ] dis of child 131 :4 70, 1977

13. Wohlfeld GM: Hyaline Membran e Disease. A]R

93:425-427, 1965

14. Ellis K, N adelhaft ]: Roentgenographic Findings in

Hyalin e Membrane disease in infants weighing

2,000 Grams and over, A]R 28(3):444 -45α 1957

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