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In the subacute category, the most common radiographic pattern is a localized lobar infiltrate, usually in the upper lobes and showing cavity formation (Figs. 23.12- 23.16). Alternatively, there may be an isolated lobar or segmental consolidation without cavitation (Figs. 23.12 & 23.13A). Isolated lung abscesses can occur and may be associated with empyema (Figs. 23.17 & 23.18). However, as in the other forms of the disease, hilar adenopathy and pleural effusions are rare.

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Fig. 23.12 A-C Subacute melioidosis in an American soldier serving in Vietnam. A Initial PA chest film shows extensive consolidation in the right lower lung near the costophrenic angle and minimal patchy pneumonitis in the left lingula adjacent to the lower heart border and in the left apex below the first anterior rib. B Follow-up film 3 days later shows beginning cavitation within the area of consolidation at the right lung base and considerable increase in size of the patchy confluent infiltrate in the left lingula and left apex, with early cavitation at the latter site. C Subsequent chest examination after 1 month of prolonged therapy with multiple antibiotics shows partial clearing of the scattered areas of pneumonia, but significant infiltrate still remains, especially at the right base and left apex. The cavities seen earlier in these two areas are no longer visible.

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Fig. 23.13 A-D Subacute melioidosis in two American soldiers serving in Vietnam. A Initial PA chest film shows a right middle lobe infiltrate. There is no cavitation, pleural effusion, or hilar adenopathy. B Follow-up PA chest film 8 months later shows residual fibrosis in the right middle lobe. The patient had fully recovered on appropriate antibiotic therapy. C PA chest film of another soldier shows multiple cavities and patchy infiltrate in the right midlung and right upper lobe simulating tuberculosis; however, B. pseudomallei was cultured. D Follow-up chest film 3 months later, after prolonged antibiotic therapy, shows only residual thickening of the minor fissure and minimal scarring in the right midlung.

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Fig. 23.14 A-C Subacute melioidosis simulating tuberculosis with cavity formation in three American soldiers who contracted their disease while in Vietnam. In all three patients, the cavitary lesions are in the right upper lobe, strengthening their similarity to tuberculosis. A A large thin-walled cavity in the right midlung with scattered areas of patchy, sometimes nodular infiltrates throughout both lungs. B PA chest film on another 37-year-old soldier shows cavitary disease in the right upper lobe and apex. There is minimal infiltrate also in the lateral aspect of the left lower lung field. The patient was initially thought to have tuberculosis, but on transfer from Vietnam to a military hospital in the United States, B. pseudomallei was cultured from his sputum. Serology showed a complement fixation titer of 1:128 and hemagglutination titer of 1:2560. While in Vietnam, he had fever, cough productive of purulent, blood-streaked sputum, chest pain and a weight loss of 50 pounds. He was treated with tetracycline for 2 months with resultant clearing of his cavitary disease. C PA chest film of another soldier showing patchy infiltrate with multiple cavities in the right upper lobe. Initial chest film taken when the patient was moderately symptomatic 7 weeks earlier showed a minimal patchy increase in density in the same area. This infiltrate increased in extent, and cavity formation was noted on a chest film taken 10 days prior to this film. The infiltrate and cavities subsequently cleared after intensive antibiotic therapy.

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Fig. 23.15 A-C Subacute melioidosis with thin-walled cavities in the right upper lobe simulating tuberculosis in an American soldier serving in Vietnam. Sputum cultures were positive for B. pseudomallei and negative for acid-fast bacilli. The patient had fever, cough with purulent, blood-streaked sputum, chest pain and weight loss. A PA view of the chest and B anteroposterior (AP) tomogram of the right upper lobe show two thin-walled cavities with virtually no surrounding inflammatory reaction in the posterior segment of the right upper lobe. C AP tomogram of the right upper lobe obtained 3 weeks later shows slight diminution in size of the lower, more medial cavity which has merged with the larger cavity above it. The patient was treated with tetracycline for 2 months with subsequent clearing of his cavitary melioidosis. The subacute or subclinical forms of melioidosis must be considered in the differential diagnosis of thin-walled lung cavities in addition to other entities, such as tuberculosis, coccidioidomycosis, and bullae.

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Fig. 23.16 A-C Subacute melioidosis with a cavity in the left upper lobe of a 33-year-old man with a 3 week history of fever, chills and sweats. A Initial chest film showed a patchy left upper lobe infiltrate in the first anterior interspace. B Subsequent AP tomogram of the left upper lobe in January 1967 shows a thin-walled cavity in the same area (arrow). There is also pleural thickening and slight fibrotic stranding at the left apex, extending from the area of cavitation towards the hilum. C The patient remained on antibiotics and a subsequent AP tomogram of the left upper lobe 1 year after the initial radiograph showed fibronodular scarring in the area of previous cavitation, as well as residual pleural and parenchymal scarring at the lung apex. The radiographic appearance of this patient's cavitary melioidosis strongly resembles that seen in tuberculosis.

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Fig. 23.17 A-D Subacute melioidosis with abscess formation in an American soldier serving in Vietnam. A Initial PA chest film of April 20, 1967, shows a soft infiltrate in the right upper lobe underlying the clavicle and first rib. B One month later, on May 20, a large thick-walled abscess cavity with air-fluid level is present in the same area of the right upper lobe. C Five days later, on May 25, the fluid in the abscess cavity has been expectorated and there is considerable patchy infiltrate in the surrounding lung. D By June 19 there has been considerable clearing of the right upper lobe infiltrate and the abscess is no longer visible. Slight residual inflammatory changes remain in the original area of involvement and also beneath the second rib.

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Fig. 23.18 A,B Large abscess caused by B. pseudomallei in a 30-year-old man with subacute melioidosis. A PA and B lateral views of the chest reveal a thick-walled abscess with fluid level in the superior segment of the right lower lobe. C Lateral and frontal chest radiographs of a 46-year-old man with melioidosis show a right upper lobe abscess with fluid level and an extensive loculated pyopneumothorax. (Courtesy of Dr. W. B. Young, London.) D Advanced cavitary disease in the left upper lobe with extensive pleural thickening along the left lateral chest wall and apex in a patient with negative tuberculous skin test and cultures, but positive indirect hemagglutination titers for B. pseudomallei. There is also slight cavitary disease in the right lung apex. (C, D from W.P Cockshott and J.H. Middlemiss: Clinical Radiology in the Tropics. Churchill Livingstone, Edinburgh, 1979).

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