Chest Radiology PreTest Self- Assessment and Review — Juzar Ali, Warren G. Summer

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Quick Reference
Suggested Reading
Pulmonary and Critical Care, Department of Medicine, and the Depart-
ment of Radiology, Louisiana State University Health Sciences Center, for
their assistance in compiling the cases and chest radiographs presented in
We dedicate this text to the patients seen at the Medical Center of
2Chest Radiology
Solitary Pulmonary Nodule3
A 34-year-old woman, a recent immigrant from Eastern Europe, is
seen with complaints of vague chest discomfort after an upper respiratory
tract infection. She is not a smoker and gives a history of BCG vaccination
b.Scar carcinoma
a.MRI of the chest
b.Fiberoptic bronchoscopy
c.Comparison of previous chest radiograph, if available, and repeat chest radi-
d.Treatment with four-drug anti-TB chemotherapy
4Chest Radiology
Solitary Pulmonary Nodule5
A 30-year-old female nonsmoker who recently moved to the U.S. from
Mexico presents with dyspnea on exertion. Her PPD is 8 mm. On physical
examination, her pulse is 110 bpm, blood pressure is 110/70 mm Hg, and
she has mild clubbing, cyanosis, and orthodeoxia. Otherwise, her physical
exam is normal. Laboratory data: Hb 14 g/dL; Hct 42%; WBCs 11,000/
differential normal. ABGs on room air: pH 7.42; P
a.Sputum for fungal culture
b.Rib series
c.CT scan with contrast of the chest
d.V/Q scan
Lesions associated with the above disorder include
a.Erythema nodosum
b.Lupus pernio
d.Oral thrush
6Chest Radiology
Solitary Pulmonary Nodule7
8Chest Radiology
A 62-year-old woman with a 30-pack-year smoking history is evalu-
ated with a history of chronic shortness of breath. She has mild left-sided
chest discomfort. She denies fever, chills, and night sweats and has no
localizing signs on physical exam. A CT-guided needle biopsy of the lesion
seen in the CXR in Fig. 4 is performed and reveals malignant cells.
a.Small cell carcinoma
b.Bronchoalveolar cell carcinoma
c.Adenocarcinoma of the lung
d.Liposarcoma of the chest wall
a.Positive sputum cytology
b.A good response to chemotherapy
Solitary Pulmonary Nodule9
Description of X-rays in This Chapter
Figure 1.
left hilum. Cardiophrenic and costophrenic angles are clear. An 0.8
Solitary Pulmonary Nodule
mo is inappropriate. Due to the peripheral nature of this lesion, a CT-guided
12Chest Radiology
nant cells. Adenocarcinoma is commonly peripheral and represents about
cially in females. Adenocarcinoma frequently presents as an incidental
finding on x-ray. The other major histological types of lung cancer tend to
have central localization and are as follows:
1.Squamous (epidermoid) carcinoma. Eighty percent are central; when
2.Small cell (oat cell) carcinoma. Believed to originate from neuroen-
docrine cells of the bronchial mucosa, these are usually central with
3.Large cell undifferentiated carcinoma with mixed malignant features.
4.Bronchoalveolar carcinoma. A variant of adenocarcinoma, these arise
from type II pneumocytes in the alveoli. They may simulate pneumonia
with focal consolidation or may present as solitary or multiple nodules.
Solitary Pulmonary Nodule
16Chest Radiology
Multiple Pulmonary Nodules17
10.Based on the CXR shown in Fig. 6, all of the following may be
a.Occupational history
b.Sputum for AFB
c.Sputum for fungus
d.History of rheumatic fever
This patients occupational history reveals exposure to iron ore,
asphalt, and dust related to working on loading docks for 10 years. The
d.Chlorine gas exposure
18Chest Radiology
Multiple Pulmonary Nodules19
20Chest Radiology
A 70-year-old man with a history of emphysema and progressive dys-
left-sided chest wall scar from a previous thoracotomy with decreased
breath sounds in the left lung field. There are wheezes and rhonchi heard
clinical history, the most likely diagnosis is
a.Left lung atelectasis with mucus plug
Multiple Pulmonary Nodules21
22Chest Radiology
A 53-year-old male smoker, unemployed with no occupational expo-
sure, is admitted with progressive shortness of breath. He has been unwell
for some time and has received multiple courses of antibiotics for bron-
exam, he is afebrile but looks ill. Lung exams reveal diffuse rhonchi and
crackles with no localizing signs. ABGs on room air show Pa
Hg with mild compensated respiratory alkalosis. Sputum for AFB is nega-
b.Hypersensitivity pneumonitis
Multiple Pulmonary Nodules23
Description of X-rays in This Chapter
Figure 5.
This x-ray shows a bilateral diffuse miliary nodular pattern
figure 6.
A bilateral nodular pattern is seen in both lung fields. However,
these nodules are predominantly in the upper zones with some patchy
areas of confluence. The bases are clear and there is no pleural disease.
Figure 7.
surgical rib changes and clips seen near the left main stem secondary to a
left pneumonectomy. Multiple nodular opacities of varying sizes are seen
An occupational history without constitutional symptoms.
X-ray that looks worse than the patients complaints, as in sarcoidosis.
History of thromboembolic disease or sepsis, as in septic emboli or pul-
monary infarcts. These are generally seen in the lower lung zones.
History of arthritis; may suggest rheumatoid nodules.
Multiple Pulmonary Nodules
pulmonale is common. Tuberculosis occurs with increased incidence in sil-
ease warrants chemoprophylaxis. Bagassosis due to exposure to sugar cane
residue presents with a hypersensitivity pneumonitis, and chlorine gas
exposure causes upper airway dysfunction. Pulmonary chlorine gas injury
requires exposure in a confined space and is followed by pulmonary leak
syndrome (ARDS) and bronchiolitis. Asbestosis refers to respiratory dys-
parenchyma characterized by increased interstitial changes in the lower
zones. Other radiographic evidence of asbestos exposure includes pleural
plaques and pleural and pericardial calcification.
With the history of a left-sided thoracotomy and
chest radiograph changes consistent with a pneumonectomy, the right-
26Chest Radiology
28Chest Radiology
Lung Masses29
A 38-year-old city worker presents with fever, chills, and cough with
left-sided chest pain 2 days after the Mardi Gras festival. She denies any
hemoptysis, weight loss, or chronic illness. Past history is unremarkable.
On physical exam, she has a BMI of 32; temperature is 101
F. She was
observed to have splinting of her right side during the inspiration CXR
a.Bronchogenic carcinoma
b.Round pneumonia
c.Alveolar sarcoidosis
d.Fungus ball
b.Increased ACE levels
30Chest Radiology
Lung Masses31
A 62-year-old female smoker presents with a history of pneumonia
6 wk ago. She has been on multiple antibiotics, and although she feels rel-
32Chest Radiology
Lung Masses33
Description of X-rays in This Chapter
Figure 9.
A large, 7
11-cm mass is seen in the left parahilar area. This
women. Also, the P450 system is more active in men and therefore the
breakdown in oxidative capacity is more active in men. Women develop
more DNA damage at lower smoker exposure levels. Twenty-five percent of
symptoms include cough, shortness of breath, hemoptysis, wheezing, and
paraneoplastic syndromes that may bring the patient to medical attention.
and protracted treatment with antibiotics being unsuccessful, further diag-
nostic steps are needed. A CT would help define location and exclude
sequestration or a posterior mediastinal mass. As a first step, bronchoscopy
and evaluation of the airways would probably yield a histopathologic diag-
nosis in this endobronchial and intrapulmonary lesion. Open lung biopsy
would be indicated only if bronchoscopy and other studies are nondiag-
36Chest Radiology
38Chest Radiology
Cavitary Lesions39
A 50-year-old woman is seen with symptoms of progressive dyspnea
and cough productive of yellow sputum mixed with blood. She also com-
plains of nasal discharge, arthalgias, and low-grade fever. Vital signs: pulse
110 bpm; temperature 99
F; respirations 19/min; blood pressure 140/90
Lung exam reveals diffuse crackles with nonlocalized areas of egophony.
Laboratory data: Hb 12 g/dL; Hct 36%; WBCs 12.8/
L with a differential
of 15% bands; BUN 30 mg/dL; creatinine 1.6 mg/dL; sodium 138 mEq/L;
protein with RBC and RBC
a.Lung abscess
b.Wegeners granulomatosis
c.Squamous cell cancer
a.High rheumatoid factor titers
b.Positive C-ANCA
c.Increased ACE levels
40Chest Radiology
Cavitary Lesions41
A 60-year-old man with a history of COPD and old TB is seen with
mild hemoptysis and chronic cough. He is HIV negative and has been ill for
about 2 wk. Vital signs: pulse 110 bpm; temperature 101
F; respirations
24/min; blood pressure 108/70 mm Hg. No skin lesions are noted. Labora-
tory data: Hb 14 g/dL; HCA 42%; WBCs 8.7/
L; BUN 24 mg/dL; creatinine
87 mm Hg. Sputum tests reveal numerous AFB-
42Chest Radiology
Cavitary Lesions43
Cavitary Lesions45
A 49-year-old woman with no smoking history presents with a sudden
bout of hemoptysis reported to be about 600 cc, increasing cough, and
dyspnea on exertion. She was diagnosed with sarcoidosis in the past and
has been on steroid treatment off and on. Her last cycle of steroids was 2
physical examination, vital signs are: pulse 106 bpm; temperature 100
respirations 34/min; blood pressure 110/68 mm Hg. On general examina-
tion, the patient appears in moderate distress, and pertinent findings
include crackles heard in the left upper lung zones. Laboratory data: Hb
creatinine 0.9 mg/dL; sodium 126 mEq/L; potassium 5.6 mEq/L; PPD neg-
ative. PFTs performed 6 mo ago show: FVC 1.8 (45% of predicted); FEV
1.0.8.L (34% of predicted); DLCO 46% of predicted. CXR is shown in Fig.
a.Sarcoidosis exacerbation
b.Cavitary carcinoma
c.Lung abscess
The therapeutic step most likely to result in the control of bleeding is
a.Restarting of steroids
b.IV amphotericin
c.Intracavitary itraconazole
d.Bronchial artery embolization
46Chest Radiology
Cavitary Lesions
48Chest Radiology
A 42-year-old black man with a history of IVDA develops low-grade
fever, night sweats, weight loss, cough, and hemoptysis. On physical exam-
ination, vital signs are: pulse 109 bpm; temperature 100
F; respirations
22/min; blood pressure 110/70 mm Hg. On general exam, the patient
appears ill and has palpable nodes in the anterior and posterior cervical tri-
angle. Laboratory data: Hb 11 g/dL; Hct 32%; WBCs 7.2/
mg/dL; creatinine 0.3 mg/dL; sodium 129 mEq/L; potassium 3.2 mEq/L;
b.Start four-drug anti-TB treatment
c.Start antifungal treatment
d.Repeat PPD and start INH chemoprophylaxis
Cavitary Lesions49
A 56-year-old male smoker with a history of chronic dry cough for
gives a remote history of aspiration of a tooth many years ago while under-
going a dental procedure. On examination, he is afebrile and has temporal
wasting. Extremities are clubbed and breath sounds are diminished in the
a.Lung abscess
b.Cavitary squamous cell carcinoma
c.Infected bulla
a.Start empirical antituberculosis therapy pending culture data
b.Begin chest physical therapy
c.Schedule a surgical consultation
d.Perform bronchoscopy
50Chest Radiology
Cavitary Lesions51
Description of Chest X-rays in This Chapter
Figure 12.
ple air-fluid levels. Surrounding this opacity and the air-fluid levels is an
ill-defined infiltrate. Note that the right apex and lower lung zones are
clear. The left lung is also clear, and no pleural or mediastinal disease is
noted. This x-ray is consistent with a necrotizing process in the posterior
segment of the right upper lobe, with an air-fluid level such as in a lung
Figure 13.
This CXR shows a bilateral process with multiple cystic
lesions primarily on the left. Lung volumes appear small and there is left
Figure 17.
This PA and lateral chest x-ray shows a large right upper lobe
mass with an air-fluid level. This mass has a very thick wall with irregular
inner margins and is abutting the mediastinum. Differential diagnosis in
this case would include lung abscess or cavitary squamous cell carcinoma.
The x-ray differential for infiltrates with areas of breakdown or cavitation and
Cavitary Lesions
The answers are 21-b, 22-b.
cavitary process on the chest x-ray are suggestive of Wegeners granulo-
options mentioned are not seen in this condition.
An upper lobe cavitary lesion in a patient with
culture out
M. avium-intracellulare
(MAC). Another possibility is nocardia infection. Actinomyces can present
as upper lobe cavitary disease but is not acid-fast-positive on smear and is
and culture criteria. The diagnosis should be suspected with symptoms of
cough, fever, and weight loss with progressive infiltrates, cavitation, and
chronic pulmonary infections are predominantly women and nonsmokers.
High-resolution CT scan typically shows multiple small nodules with
bronchiectasis. The diagnosis must be established bacteriologically since
some nontuberculous mycobacteria are commonly found in nature and
contamination of specimen can occur. Therefore, the diagnosis of MOTT
pulmonary disease requires the following: three positive cultures with neg-
ative AFP smears; two positive cultures and one positive smear; a single
bronchial specimen with a positive culture of 2 to 4
growth; a positive
AFB smear and a positive culture of any biopsy specimen; granuloma by
biopsy with one positive culture from any respiratory specimen; or a
growth of MAC from any usually sterile extrapulmonary site. Although
transient infection with spontaneous resolution occurs, significant growth
on culture means disease is present. Mycobacterial disease due to non-
tuberculous mycobacteria is now more common than tuberculosis in the
United States. It is generally prevalent in specific areas such as the South-
east and the Gulf Coast region. According to the CDC, one-third to one-
fourth of all isolates of mycobacteria are due to nontuberculous
mycobacteria. Natural waters appear to be the likely environmental source
of these organisms, which can be isolated from tap water or even hospital
water. Person-to-person transmission is thought to be unlikely. Clinical
syndromes of MAI disease in nonimmune non-HIV individuals occur in
dromes may present as upper lobe infiltrates or cavitary or solitary nodules.
54Chest Radiology
Patients can develop chronic bronchiectasis or cystic fibrosis. In nonsmok-
and purulent sputum for an average of 6 mo may be present.
The answers are 24-d, 25-d.
Cavitary Lesions
1000 IU is characteristic. An increase in IE precedes radiographic findings
and is usually a good index of disease activity. A normal IE in a patient with
suspected ABPA virtually rules out the diagnosis. ABPA can be classified
into stages. Stage 1 is acute, in which treatment with corticosteroids assures
dramatic improvement. Stage II is remission, which may last for months or
years. Stage III is recurrent exacerbation characterized by acute-phase
requiring continuous corticosteroids. Stage V is end-stage fibrotic lung dis-
ease. As a clinical follow-up, serial IgE testing every 3 mo is advisable.
Aspergillosis may be sporadically isolated from sputum culture, but this is
not necessary for diagnosis.
The answers are 26-a, 27-b.
This clinical and radiographic pre-
sentation is seen in TB. Four-drug anti-TB treatment should be promptly
started based on this clinical and radiological suspicion. There is no role for
single-drug chemoprophylaxis in this case. ACE levels are of some prog-
nostic value in sarcoidosis. Starting empirical antifungal treatment would
be inappropriate in this clinical context.
The answers are 28-b, 29-d.
The clinical history suggests a
chronic illness with stigmata of an underlying malignancy. A large, thick-
walled abscess formation may be seen secondary to a postobstructive pneu-
monia. Bronchoscopy is helpful to see if there is a lesion causing this
obstruction and is the appropriate next step.
56Chest Radiology
Hyperlucent Lung59
60Chest Radiology
Hyperlucent Lung61
A 38-year-old man is admitted with progressive shortness of breath
and cough. He denies any fever, chills, or purulent sputum production. He
Hyperlucent Lung63
64Chest Radiology
Hyperlucent Lung65
A 39-year-old man, a smoker since age 16, is seen in the clinic with
complaints of fever, cough, and production of yellowish sputum. He has
been chronically short of breath, but these symptoms have increased over
looks ill. Lung exam reveals diffuse wheezing with egophony and whisper-
of 55 mm Hg on room
air, and sputum is negative for TB. Chest x-rays are shown in Fig. 20.
a.Arrange with intervention radiology to do a needle aspiration
b.Consult thoracic surgery for lung reduction surgery
c.Start antibiotic and O
d.Admit patient in an isolation room
Appropriate measures at the first follow-up should include
a.Pneumococcal and influenza vaccine
b.Allergy testing
68Chest Radiology
Hyperlucent Lung69
Description of Chest X-rays in This Chapter
Figure 18.
These x-rays show a marked degree of hyperinflation depicted
radiographically by increased lung volume with flattened diaphragm and
widened interspaces. Attenuation of the pulmonary vasculature in the
senting focal emphysema. Blebs are smaller airspaces occurring within the
subpleural or pleural layers. A cyst is a rounded airspace with a well-defined
wall consisting of epithelium or fibrous tissue containing air, but not neces-
sarily associated with emphysema. Cysts may contain varying amounts of
ated with increasing paraseptal emphysema forming bullae refers to the
vanishing lung syndrome (see below).
is seen in the first few months of life and refers to
a large hyperlucent lobe associated with compressive and mass effect on
the adjacent structures.
refers to hyperlucent and hyperinflated air-
spaces adjacent to areas of deformity, atelectasis, or resection of lung
and represents overexpansion without actual lung destruction.
is associated with conditions of fibrosis and scarring
and associated honeycombing as in stage 4 sarcoidosis or chronic in-
flammatory conditions.
The answers are 32-b, 33-d.
The CXR shows a large bulla,
which accounts for the symptoms of this patient. Discrepancy in total lung
72Chest Radiology
74Chest Radiology
Cysts and Cystic-Appearing Lesions75
A 27-year-old man is seen with a history of chronic sinus and pul-
76Chest Radiology
Cysts and Cystic-Appearing Lesions77
A 29-year-old woman is referred to the clinic with a history of
repeated respiratory tract infections. There is no significant travel history
and she denies any possibility of foreign body aspiration. On examination,
Based on the history and CXR, the next diagnostic step should be
a.Contrast CT scan of the chest and upper abdomen
78Chest Radiology
Cysts and Cystic-Appearing Lesions79
A 24-year-old male law student presents with a 3-wk history of
increasing dyspnea. He has a history of chronic sputum production of
was hospitalized for a left pneumothorax. He is on inhaled bronchodilator
d.Pectus excavatum
80Chest Radiology
Cysts and Cystic-Appearing Lesions81
Description of X-rays in This Chapter
Figure 21.
the lower and middle zones. These cysts have distinct walls and air-fluid
levels. This picture is consistent with bilateral lower lobe and lingular
bronchiectasis. Note the large pulmonary arteries, which may suggest sec-
ondary pulmonary hypertension and cor pulmonale.
Figure 22.
small cystic-appearing shadows. There is dextrocardia with situs inversus
totalis, i.e., a right aortic arch, the stomach bubble on the right side, and
Figure 23.
der. These cystic-appearing shadows originate from the left lower lobe
bronchus. This picture is consistent either with left lower lobe bronchiec-
Figure 24.
This x-ray shows a bilateral cystic-appearing lesion with air-
fluid levels consistent with cystic bronchiectasis. The opacities are predom-
inantly in the upper zones. There is hyperinflation with flattened diaphragm
and areas of hyperlucency in the left upper lobe peripherally. This is consis-
tent with chronic bronchiectasis and/or cystic fibrosis; the latter is more
likely due its upper zone predominance.
Bronchiectasis refers to an irreversible bronchial dilatation with bronchial
wall thickening as a result of infection and inflammation. It can be congen-
ital, as seen in cystic fibrosis and immotile cilia syndromes. Symptoms
include chronic recurrent cough, sputum production, and hemoptysis. Life-
threatening hemoptysis can occur. Conditions associated with bronchiecta-
sis include airway obstruction, foreign body impaction, chronic airway or
inhalational injury, allergic bronchopulmonary aspergillosis/mycosis (ABPA/
ABPM), cystic fibrosis, and ciliary dyskinesia/immotile cilia syndromes,
recurrent aspiration, and idiopathic bronchiectasis. Focal bronchiectasis can
also result from bronchial stenosis with occlusion due an endobronchial
lesion with mucoid infection or as a result of a prior severe pneumonia.
Impaired mucociliary clearance and hypogammaglobulinemia have lower
lobe predominance. Cystic fibrosis has upper lobe predominance, whereas
bronchiectasis associated with ABPA is central in location. Bronchiectasis is
cal or tubular bronchiectasis is due to uniform fusiform dilation and is seen
astram-track lines on x-ray. Varicose bronchiectasis appears as beaded
with alternating areas of dilatation and constriction as seen in cystic fibrosis.
Saccular or cystic bronchiectasis is manifested by marked bronchial dilation
with peripheral ballooning of the cystic spaces and air-fluid levels and is
often associated with bronchial stenosis. Traction bronchiectasis is the result
of fibrotic distortion of the lung caused by infection, radiation, or end-stage
lung disease, and is seen most commonly in the lung periphery.
The answers are 36-a, 37-c.
The history is suggestive of
bronchiectasis, and the bilateral cystic-appearing lesions on the CXR are
consistent with that diagnosis. Cystic fibrosis is generally predominant in
the upper zone. Sarcoidosis rarely presents with this history, and the fibrotic
changes in sarcoidosis are usually in the upper lobes. Allergic bronchopul-
monary aspergillosis is seen with an underlying asthmatic condition. The
drainage. Steroids would only be indicated if there is severe respiratory fail-
ure and bronchospasm. Bronchoscopy and surgical consult are inappropri-
The answers are 38-b, 39-b.
The chest x-ray shows dextrocar-
dia and bilateral bronchiectasis as seen in immotile cilia syndrome. Karta-
gener syndrome is the immotile cilia syndrome with situs inversus totalis.
This is an autosomal recessive disease characterized by structural and func-
tional abnormalities of the cilia resulting in impaired mucus clearance,
recurrent infection, chronic sinobronchial infections, and infertility.
Frontal sinuses are often absent or hypoplastic. Chronic mucus impaction
and infections lead to bronchiectasis.
The chest x-ray and clinical history suggest
bronchiectasis of the left lower lobe. Bronchograms are not done anymore
because of frequent complications and the fact that a CT scan can confirm
the diagnosis. Bronchoscopy would not reveal any additional information
84Chest Radiology
The answers are 41-a, 42-a, 43-c.
The history and chest x-ray
are consistent with cystic fibrosis with bilateral cystic upper zone predomi-
88Chest Radiology
Diffuse Interstitial Disease89
A 65-year-old woman from Honduras complains of arthralgias and dif-
90Chest Radiology
Diffuse Interstitial Disease91
A 48-year-old female nurse is seen with complaints of cough. She has
been treated for bronchitis without much improvement. On exam, she is
b.Skin lesion
c.Bony cysts
92Chest Radiology
Diffuse Interstitial Disease93
A 56-year-old black male nonsmoker is seen with a history of dyspnea
on walking two blocks and chronic chest congestion and cough. He has
been followed for progressive shortness of breath after his CABG. Recently,
he was ill with a flulike illness, but he denies any fever or chills presently.
Past history reveals a GI clinic follow-up for inflammatory bowel disease for
which he has been on chronic steroid therapy off and on. On physical exam-
ination, vital signs are: pulse 110 bpm; temperature normal; respirations
24/min; blood pressure 120/78 mm Hg. General exam: patient appears frail
but in no distress. Pertinent findings: coarse rhonchi and scattered expira-
tory wheeze with squeaks. Heart exam reveals normal S
There is no hepatomegaly or pedal edema. Laboratory data: Hb 11 g; Hct
94Chest Radiology
Diffuse Interstitial Disease95
A 50-year-old woman is admitted with progressive shortness of breath.
96Chest Radiology
Diffuse Interstitial Disease97
The findings seen on the CXR in Fig. 30 are least likely to be seen in
98Chest Radiology
Description of X-rays in This Chapter
Figure 25.
lung fields. Cardiac shadows are normal and no cephalization of flow
100Chest Radiology
have rheumatoid arthritis than in women with RA. In 20% of patients, the
lung disease may precede the development of arthritis.
The answers are 44-d, 45-a, 46-b.
cough and dyspnea in a 49-year-old woman without any specific arthritis
or skin lesions, and the presence of clubbing and bilateral Velcro rales, sug-
gest idiopathic pulmonary fibrosis. This disease has a slightly male pre-
dominance and usually presents in the sixth decade. Associated findings in
this condition include a positive ANA/RA and an increased sedimentation
rate. Increased IgE is not seen in idiopathic pulmonary fibrosis. The pul-
monary function test in this condition would show a restrictive pattern.
The absence of specific arthritis and skin lesions makes rheumatoid lung or
sarcoidosis less likely.
The answers are 47-b, 48-a.
Symptoms of arthralgias and diffi-
increased CPK and aldolase suggest polymyositis. Interstitial disease is
malignancy; carcinoma of the pancreas is most common. Other complica-
tions include respiratory failure and aspiration. The response to steroid
The answers are 49-c, 50-d.
The physical signs are inconsistent
with an infectious process. The CXR shows hilar, paratracheal LN, and
parenchymal disease. Sarcoidosis may be associated with uveitis, skin
lesions, bony cysts, and hypercalcemia, which is due to abnormal vitamin
patients with pulmonary involvement may experience weight loss, fatigue,
fever, cough, or shortness of breath. Hemoptysis is rare unless it is asso-
102Chest Radiology
ing pneumonia (BOOP). There are no signs of CHF. Bronchiolitis refers
to inflammation involving the small airways. Proliferative bronchiolitis is
a result of organizing intraluminal exudates, and, when associated with
inflammation infiltrating the airspace and interstitium, is referred to as
BOOP. Typically, it is seen with a history of several weeks of nonproductive
cough and dyspnea after an upper respiratory tract infection in a middle-
aged person. A prolonged course of steroids is needed to control the symp-
toms. There is an increased risk of mycobacterial infections in patients on
chronic steroid therapy.
The answers are 53-c, 54-b.
Inhalation of organic dusts derived
For each item below, match the scenario with the
appropriate x-ray.
106Chest Radiology
Diffuse Airspace Disease107
108Chest Radiology
Diffuse Airspace Disease109
A 44-year-old woman is admitted with hemoptysis and progressive
shortness of breath. On physical examination, her vital signs are: pulse 110
bpm; temperature 99
F; respirations 22/min; blood pressure 118/68 mm
Hg. She is in mild distress and her lung exam is normal except for occa-
sional crackles. Laboratory data: Hb 9.8 g/dL; Hct 30%; WBCs 9.0/
ferential normal; BUN 46 g/dL; creatinine 1.9 mg/dL. Urinalysis shows
RBC casts. ABGs on room air: pH 7.42; P
Pulmonary function tests are within normal limits except for DLCO, which
is 110% of predicted. Based on this clinical scenario, which of the above
a.Fig. 31
b.Fig. 32
c.Fig. 33
d.Fig. 34
A 62-year-old man is admitted with chest pain. He has four-vessel dis-
ease and undergoes CABG. On the third postoperative day, the patient
develops increasing shortness of breath with diffuse crackles on lung exam.
Laboratory data: Hb 12 g/dL; Hct 36%; WBCs 9.8/
L; differential normal;
BUN and creatinine normal. ABGs on 3% Ventimask: pH 7.50; P
a.Fig. 31
b.Fig. 32
c.Fig. 33
d.Fig. 34
A 38-year-old female smoker is admitted with progressive shortness of
breath and productive cough with copious amounts of white mucoid spu-
tum. On physical examination, vital signs are: pulse 98 bpm; temperature
normal; respirations 35/min; blood pressure 110/80 mm Hg. The patient is
in mild distress and has bilateral crackles in the midlung fields with areas
of egophony in the right posterior lung zone. ABGs on room air: pH 7.47;
a.Fig. 31
b.Fig. 32
c.Fig. 33
d.Fig. 34
110Chest Radiology
A 72-year-old man with a history of COPD and chronic sputum pro-
, with a long-standing history of reflux esophagitis
and difficulty swallowing, is admitted with shortness of breath and fever.
On physical examination, his vital signs are: pulse 128 bpm; temperature
F; respirations 34/min; blood pressure: 98/65 mm Hg. He appears
frail and has bilateral crackles and rhonchi on lung exam. Laboratory data:
L; BUN 56 mg/dL; creatinine 2.8
mg/dL; sodium 128 mEq/L; potassium 3.2 mEq/L. ABGs on room air: pH
a.Fig. 31
b.Fig. 32
c.Fig. 33
d.Fig. 34
Diffuse Airspace Disease111
Description of X-rays in This Chapter
Figure 31.
This x-ray shows bilateral airspace opacities that are patchy in
nature with lower zone segmental/lobar distribution. Air bronchograms are
Figure 32.
Sternal wires are seen indicating sternotomy s/p CABG. There
are diffuse airspace opacities. Cardiac size is at the upper limits of normal;
marked increased hilar fullness suggests increased pulmonary vasculature.
Figure 33.
This CXR shows increased lung volume with signs of hyper-
cardiac shadow is narrow and tubular in shape. Bilateral patchy opacities
are seen throughout the lung fields.
Figure 34.
Diffuse bilateral airspace opacities with air bronchograms are
seen throughout the lung fields.
of breath and diffuse airspace opacity is consistent with pulmonary hemor-
rhage. Increased DLCO is consistent with intraalveolar hemorrhage. Causes
of diffuse pulmonary hemorrhage include vasculitis/capillaritis with its
systemic causes and manifestations, pulmonary-renal syndromes such as
Goodpasture syndrome, bleeding diathesis in an immune-compromised
host, or idiopathic hemosiderosis.
This patient has undergone CABG and has devel-
oped pulmonary edema and acute respiratory distress syndrome (ARDS).
Diffuse Airspace Disease
has a poor prognosis. Adenopathy, effusion, and cavitation are uncommon.
CT patterns may show airspace disease and bulging fissures or a crazy
paving pattern. Bronchoalveolar carcinoma is classified as a subtype of
adenocarcinoma that has a tendency to spread locally through the lung
structure and stroma. Bronchoalveolar carcinoma accounts for 9% of all
lung tumors and is increasing in prevalence. Other features are a high
occurrence in nonsmokers and a comparatively high female-to-male ratio.
Survival is usually less than 3 years among patients with diffuse disease.
Lobar consolidation is associated with poor prognosis.
with swallowing difficulty. It frequently presents with a nonspecific diffuse
airspace infiltrate on the CXR. Pneumonia usually results from aspiration of
infected material from the oral pharynx and esophagus into the respiratory
individuals with neuromuscular disease or esophageal disease with reflux.
the right lower lobe is commonly affected. Bilateral lower lobe basilar infil-
may produce diffuse infiltrates as seen in this patient. Although 90% of the
time anaerobic bacteria are found, infection is usually polymicrobial.
114Chest Radiology
116Chest Radiology
Focal Airspace Homogeneous Opacities117
A 32-year-old female nonsmoker is admitted with a 5-wk history of
intermittent hemoptysis. She denies any sputum production, fever, or
repeated infections. There is no history of contact with TB. On physical
examination, the patient is afebrile; she has dullness on percussion and
decreased breath sounds in the LLL zone posteriorly. CV exam is normal.
PPD is 4-mm induration. Bronchoscopy shows a polypoid lesion partially
procedure. Bronchial washings are negative for malignancy and the biopsy
a.LLL pneumonia
b.LLL atelectasis
d.Pleural effusion
The clinical, radiological, and endoscopic features described are con-
a.Endobronchial carcinoid
c.Bronchoalveolar cell carcinoma
d.Primary TB
118Chest Radiology
Focal Airspace Homogeneous Opacities119
A 56-year-old male smoker is referred with symptoms of weakness,
to having pain in the right shoulder and axilla off and on for the prior 6 mo.
He denies any exposure to TB and has a negative PPD skin test. Routine
laboratory tests are normal. CXR is shown in Fig. 37.
b.Fractured clavicle
c.Pancoast tumor
d.Chest wall lipoma
a.Horner syndrome
b.Lofgren syndrome
c.Sjgren syndrome
d.Hertford syndrome
120Chest Radiology
Focal Airspace Homogeneous Opacities121
A 26-year-old woman with a past history of seizure disorder is admit-
ted to the medical ICU with status epilepticus. Due to continued seizures,
she is placed in a barbiturate coma. As part of supportive measures, she is
intubated, placed on a mechanical ventilator, and given IV fluids through a
central line. She remains stable overnight. In the morning, however, the
respiratory therapist reports that she has had excessive mucopurulent
122Chest Radiology
Focal Airspace Homogeneous Opacities123
Description of X-rays in This Chapter
Figure 35.
This x-ray shows a large homogeneous density in the right
placement of the horizontal fissure. No air bronchograms are seen within
the opacity. There is a double density within the opacity, suggesting a mass
the right upper lobe represents collapse with posterior expansion of the
Figure 36.
are terms used interchangeably. Associ-
increased density and usually loss of volume in that lobe. The x-ray signs
of lobar atelectasis may be divided into direct and indirect signs. The direct
sign is the displacement of the fissure. The indirect signs are local increase
in density, elevation of the hemidiaphragm, displacement of the medi-
astinum, compensatory hyperinflation and displacement of the hilum,
approximation of the ribs, absence of air bronchogram, and absence of vis-
ibility of the interlobar artery. This sign is especially seen in left lower lobe
direction of the collapse is inferior, medial, or posterior and forms a trian-
ipsilateral hilum is pulled inferiorly and decreases in size.
Pulmonary atelectasis or collapse on chest radiograph has been well
have been used interchange-
ably and at times confusingly. One of the most reliable signs of pulmonary
collapse and loss of volume is the displacement of the fissures and medi-
astinal structures. Several types of atelectasis have been described based
Focal Airspace Homogeneous Opacities
carcinoma with right upper lobe atelectasis. Other choices present as non-
homogeneous airspace disease with either air bronchograms or cavity for-
126Chest Radiology
Focal Airspace Homogeneous Opacities
d.Start antifungal therapy
Regarding the above diagnosis, which statement is least likely?
a.Seen in non-immune-compromised patients.
b.Prompt improvement usually occurs with treatment.
c.History of malaise and foul-smelling sputum is common.
d.Complications may include pleural effusion.
130Chest Radiology
Focal Airspace Nonhomogeneous Opacities131
A 69-year-old man with a history of chronic obstructive pulmonary
disease/chronic bronchitis is admitted with increasing sputum production,
fever, chills, and decreased O
lobe nonhomogeneous opacity. He is treated with IV antibiotics and
improves. On the fourth hospital day, prior to discharge, CXR is repeated
and the radiologist reports that there is no change as compared to the
admission x-ray. Chest x-rays are shown in Fig. 40. What will you do next?
a.Obtain a CT scan to rule out abscess
b.Defer discharge and resume IV antibiotics
c.Schedule a pulmonary consult for bronchoscopy to improve bronchial drainage
d.Discharge the patient on oral antibiotics
132Chest Radiology
Focal Airspace Nonhomogeneous Opacities133
Focal Airspace Nonhomogeneous Opacities135
A 34-year-old woman is admitted with a history of fever, chills, and
136Chest Radiology
Focal Airspace Nonhomogeneous Opacities137
A 54-year-old male nonsmoker is seen with complaints of a flulike ill-
138Chest Radiology
Focal Airspace Nonhomogeneous Opacities139
Descriptions of X-rays in This Chapter
Figure 39.
lobe infiltrate has air bronchograms and minimal loss of volume. Addition-
ally, a non-homogeneous opacity in the right lower zone obscuring the
right heart border indicates that the right middle lobe is involved.
Figure 40.
sion. This CXR is consistent with the left lower lobe necrotizing pneumonia
opacity that has air bronchograms and that may have segmental or lobar
Focal Airspace Nonhomogeneous Opacities
loss in the affected segment with concomitant effusion, pneumatocele, and
The answers are 69-b, 70-c, 71-c.
acquired pneumococcal pneumonia will have positive blood cultures. This
pneumonia usually responds well to treatment. Foul-smelling sputum and
a generalized history of chronic malaise are uncommon in community-
acquired pneumonia.
This patient with chronic obstructive pulmonary
disease has left lower lobe pneumonia. The clinical history suggests that
the patient improved on the fourth hospital day of treatment. Chest x-ray
improvement usually lags behind and does not temporally correspond
with clinical change. In this case the patient is improving and therefore the
best option is to discharge the patient on continued antibiotics. There is no
indication for either deferring the discharge or resuming IV antibiotics on
the basis of a nonresolving x-ray at this stage. Bronchoscopy for drainage
would not be indicated, and obtaining a CT scan would not alter the treat-
The answers are 73-a, 74-b, 75-d.
ical picture are consistent with pneumonia. The bulging fissure with a
although it can occur more frequently with
pneumonia would show cavitary disease with loss of volume. A loculated
empyema presents as a pleural base opacity. Based on the diagnosis of pneu-
immune-compromised status of the patient as well as the extent of the
142Chest Radiology
Focal Airspace Nonhomogeneous Opacities
146Chest Radiology
For each item below, match the scenario with the
appropriate x-ray.
148Chest Radiology
Description of X-rays in This Chapter
Figure 43.
This is an anterior-posterior film with reasonable inflation of
the right lung. The patient is not intubated, but the monitoring wires,
A pneumonectomy is typically performed through the posterior lateral tho-
racotomy for resection of bronchogenic carcinoma. The postpneumonec-
tomy pleural space slowly accumulates serosangineous fluid, and an air-fluid
level may persist for months. Increased air in the hemithorax signals the
shift of the mediastinum. The history and symptoms of COPD account for
the physical signs noted in the left lung. The bronchial breath sounds heard
on the right side anteriorly are due to transmitted sounds from the trachea.
This patient has signs of left-sided atelectasis prob-
ably due to an endobronchial obstruction or a mucus plug. Atelectasis is
neous opacity on the same side. The rib spaces are narrower than on the
right and there are no rib changes suggesting a pneumonectomy or any
The physical signs and the chest radiograph are
consistent with a massive left-sided pleural effusion. The contralateral
mediastinal shift can also be seen secondary to a pleural or lung mass on
the left side. However, masses of that degree are rare.
152Chest Radiology
Pleural Disease155
156Chest Radiology
Pleural Disease157
A 41-year-old man is admitted with severe shortness of breath. He
ing after meals. On physical examination, vital signs are: pulse 110 bpm;
temperature 98
F; respirations 24/min; blood pressure 110/70 mm Hg.
Pertinent findings: dullness to percussion on the left posterior chest with
decreased breath sounds. A patchy area of egophony is heard over the left
upper lung field posteriorly. PPD is 15 mm. CXR is shown in Fig. 47. The
a.Aspiration pneumonia
b.Community-acquired pneumonia
c.Pleural effusion
d.Left lung atelectasis
158Chest Radiology
Pleural Disease159
A 44-year-old man with a history of chronic bronchitis is admitted
with severe shortness of breath and left-sided chest pain. CXR is shown in
d.Subendocardial infarct
a.Decreased breath sounds on the left side with stony dullness on percussion
b.Absent breath sounds with hyperresonance on the left side
c.Decreased breath sounds with rhonchi bilaterally
d.Bilateral crackles with an S
a.Insertion of a chest tube
b.Pleural tap
c.Treatment of heart failure
d.Surgical exploration
160Chest Radiology
Pleural Disease161
162Chest Radiology
A 60-year-old man is admitted for elective hernia repair. He has a 40-
pack-per-year smoking history and worked as a construction worker for 20
years. He complains of shortness of breath and occasional blood-streaked
x-rays (Fig. 49) are due to
a.Chronic bronchitis
c.Environmental occupational exposure
d.Congestive heart failure
Pleural Disease163
A 70-year-old male smoker is seen in the clinic with symptoms of
cough and sputum production. He is afebrile. On lung exam, there are left-
sided crackles and rhonchi with egophony in the LUL. The patient is
treated for acute exacerbation of chronic bronchitis. Sputum is negative for
AFB. The changes on the patients CXR (Fig. 50) on the left side are due to
a.Chronic bronchitis
b.LUL pneumonia
c.Old granulomatous disease
d.Asbestos exposure
164Chest Radiology
Pleural Disease165
A 53-year-old female nonsmoker is being evaluated with symptoms of
progressive shortness of breath. She has a past history of trauma to the
right side of the chest. There is no history of asthma, sputum production,
or recent chest pain. CXR is shown in Fig. 51.
a.Calcified cyst
b.Organized hemothorax
Pulmonary function tests will show
a.Obstructive limitation with bronchodilator response
b.Normal lung volumes
c.Restrictive disease
d.Obstructive disease with no bronchodilator response
166Chest Radiology
Pleural Disease167
Description of X-rays in This Chapter
Figure 46.
ground. The very sharp edge along the left heart border represents the con-
meniscus sign is seen usually on upright PA and lateral films. A large
pleural effusion may opacify the entire hemithorax, creating a mass effect
effusion may be overlooked because it mimics elevation of the hemi-
diaphragm. Air in the stomach may make the presence of effusion apparent
on the left. A lateral peak of the diaphragm often indicates the presence of
subpulmonic effusion. Decubitus positioning confirms the effusion if it is
mobile. Fluid located within the fissure may produce a pseudotumor,
which can simulate an intrapulmonary mass in one or more projections.
However, the characteristic elliptical shadow indicates the true nature of
the density. A sharp horizontal interface indicates a fluid level and is diag-
nostic for a hydropneumothorax. Lateral decubitus examination is the
170Chest Radiology
the pleura due to the infection or tumor. The incidence of parapneumonic
pleural effusion is dependent upon the organism; 10% of pneumonias
caused by pneumococci can cause parapneumonic effusion. Fifty percent of
pneumonias caused by staphylococci can cause effusion. Exudates have
increased protein, increased LDH, and increased ratios. Bilateral effusions are
usually transudates. Unilateral effusions are most often exudates; left-sided
effusions occur due to rupture of the esophagus, dissecting aneurysm, or
traumatic injury to the aorta. Pancreatitis also typically leads to left-sided
effusion. Pleural thickening and enhancement on CT usually indicates an
thorax; its causes include trauma, malignancy, embolism, and, rarely, pleural
left lung due to mucus plugging or aspiration would produce a homoge-
pleural effusion very likely.
The answers are 84-a, 85-b, 86-a.
172Chest Radiology
174Chest Radiology
Pulmonary Vascular Disease175
A 34-year-old female cab driver, a smoker, is admitted with acute
shortness of breath and mild hemoptysis. Her review of systems is other-
wise unremarkable. Physical examination: pulse 100 bpm; temperature
F; respirations 21/min; blood pressure 160/84 mm Hg. The patient is
overweight with a BMI of 30. Other pertinent findings: HEENT exam is
unremarkable; lungs have decreased breath sounds with crackles in both
parasternal area. Extremities reveal trace bilateral pedal edema. Laboratory
L. EKG shows mild LV strain with
no acute current of injury. ABGs on room air: pH 7.38; P
a.Mycoplasma/atypical pneumonia
b.Obstructive sleep apnea
c.Chronic bronchitis
d.Pulmonary embolism
176Chest Radiology
Pulmonary Vascular Disease177
Pulmonary Vascular Disease179
A 28-year-old G1, PO 26-wk pregnant woman is seen in the OB clinic.
She has a past history of bronchial asthma that has been well controlled for
the last year by inhaled steroids. She states that she has noted increasing
shortness of breath for the last 3 days. On examination, she appears
has a pulse of 110 bpm; normal temperature; respirations 32/min; blood
pressure 160/90 mm Hg. Heart exam: NSR without any gallop. A grade 2/6
systolic murmur in the pulmonic area is heard. Lung exam is clear to aus-
cultation; abdomen exam confirms a 26-wk gravid uterus. Laboratory data:
L with normal differential; BUN 23
mg/dL; creatinine 0.9 mg/dL; sodium 136 mEq/L; potassium 4.2 mEq/l.
ABGs on room air: pH 7.34; P
L/min. Chest x-rays are shown in Fig. 54.
180Chest Radiology
Pulmonary Vascular Disease181
Pulmonary Vascular Disease183
A 24-year-old female graduate student reports increasing shortness of
breath with exercise and has recently noticed dyspnea on mild activity. One
day before presenting at the office, she experienced sudden loss of con-
sciousness while shopping at a grocery store. On physical examination,
vital signs are: pulse 88 bpm; temperature 97.8
F; respirations 18/min;
blood pressure 100/70 mm Hg. BMI is 34. ABGs on RA: pH 7.43; P
87 mm Hg. Chest x-rays are shown in Fig. 55.
a.A loud A
on cardiac auscultation
b.Right arm swelling
c.Rib notching
d.A loud P
on cardiac auscultation
184Chest Radiology
Pulmonary Vascular Disease185
Description of X-rays in This Chapter
Figure 52.
An increase in pulmonary artery pressure is called
The various mechanisms of this increase include: (1) increase in left atrial
pressure, as seen in mitral stenosis and left ventricular failure. This is fur-
ther discussed in Chap. 15. (2) Increase in pulmonary blood flow, as occurs
causes no structural distortion in the vascular bed, since capillary distensi-
bility and recruitment compensates for this increased pressure. Later, how-
ever, sustained increased pressure causes changes in small vessels with
development of right-to-left shunt. (3) Increased pulmonary vascular resis-
It is related to release of mediators such as serotonin and cat-
echolamines. In pulmonary thromboembolic disease, the vessels are ob-
structed by thrombi or circulating cells, as seen in fat or air embolism.
Further, pulmonary hypertension can occur when the capillary bed is
obliterated as in pulmonary fibrosis or veno-occlusive disease. In some
cases, several pathogeneses contribute to the elevated pressure at the same
time. Primary pulmonary hypertension is defined as a disorder of un-
Pulmonary Vascular Disease
material produce a more linear opacity. Other forms of granulomas or
inhalation exposure do not produce these chest radiograph changes.
Mycoplasma or atypical pneumonia may present
with a similar radiographic picture, but in the absence of an acute febrile
illness, that diagnosis seems unlikely. Chronic bronchitis is a clinical diag-
nosis and is defined per ATS criteria as a history of chronic sputum pro-
years. The chest x-ray may show large pulmonary vessels if there is long-
apnea (OSA) are overweight, there is no history of hypersomnolence, sleep
fragmentation, sleep disorder, or other clinical evidence of sleep apnea syn-
drome. The clinical scenario presented is suggestive of pulmonary em-
radiograph depicting those changes and representing congestive atelectasis
are consistent with that diagnosis.
The answers are 94-b, 95-c.
ical scenario with a high likelihood of pulmonary embolism in a high-risk
patient. The chest radiograph is often unimpressive or normal, as in this
case. However, congestive atelectasis, as mentioned in the previous ques-
tion, moderate bloody pleural effusion, and nodular or patchy infiltrates
can be seen. In some cases unilateral oligemia (Westermark sign) is recog-
Hamptons hump
is a term used to define pulmonary lobules filled
with blood. These are triangular pleural-based infiltrates with their apex
toward the hilum. The increased alveolar arterial gradient seen on the arte-
188Chest Radiology
The answers are 96-a, 97-a.
The chest x-ray shows large pul-
monary arteries, and this, coupled with the clinical scenario, is consistent
with primary pulmonary hypertension (PPH). As mentioned in the general
likely to be present would be a loud P
Pulmonary Vascular Disease
192Chest Radiology
Mediastinal Compartments193
A 45-year-old woman from eastern Louisiana is seen with a history of
difficulty swallowing, and chest discomfort. Examination reveals progres-
sive proximal muscle weakness. Chest x-ray is shown in Fig. 57.
a.Pericardial cyst
c.Bronchogenic cyst
d.Enteric cyst
a.Eaton-Lambert syndrome
194Chest Radiology
Mediastinal Compartments195
196Chest Radiology
A 38-year-old male truck driver is seen with complaints of chronic
cough. He has been living in the midwestern U.S. for many years. About 2
upper limit is 30 U/mL). Among other routine tests now done, a chest
Mediastinal Compartments197
Mediastinal Compartments199
A 30-year-old African American woman presents with decreased exer-
cise tolerance, low-grade fever, fatigue, and cough. She denies any travel or
exposure history. On lung exam, she has faint crackles bilaterally. There is
200Chest Radiology
Mediastinal Compartments201
Mediastinal Compartments203
A 41-year-old male schoolteacher, a nonsmoker, presents with light-
headedness and increased shortness of breath with lack of stamina and
chest pain. On physical examination, vital signs are normal. The patient is
overweight with a BMI of 33. CVS exam reveals a left parasternal heave
radiographs are shown below in Fig. 60.
a.Mitral stenosis
b.Pulmonary hypertension
c.Chronic bronchitis with cor pulmonale
d.Deconditioning due to obesity
a.Pulmonary function tests
b.Exercise test
d.Pulmonary rehabilitation with an aggressive exercise program
204Chest Radiology
Mediastinal Compartments205
A 60-year-old woman from Honduras with a history of uncontrolled
nausea, vomiting, diaphoresis. On physical examination, vital signs are:
pulse 100 bpm; temperature normal; respirations 25/min; blood pressure
tated. Pertinent findings include: heart examnormal sinus rhythm, with
soft systolic murmur, loud A
; funduscopysevere exudates and hemor-
rhages. Laboratory data: Hb 11 g/dL; Hct 33%; WBCs 11.5/
mg/dL; creatinine 1.3 mg/dL; sodium 129 mEq/L; potassium 4.5 mEq/L.
Cardiac enzymes are normal. EKG shows LVH with strain. Chest radi-
ographs are shown below in Fig. 61.
a.Left ventricular aneurysm
b.Congestive heart failure
d.Aortic aneurysm
While controlling the patients BP, what is the immediate next diag-
b.CT scan
c.Ultrasound of chest
d.Repeat chest x-ray with lordotic view
Mediastinal Compartments207
208Chest Radiology
Mediastinal Compartments209
Mediastinal Compartments211
A 68-year-old female smoker is admitted with progressive weakness,
weight loss, and dysphagia. Physical exam: pulse 110 bpm; temperature
normal; respirations 18/min; blood pressure 110/60 mm Hg. The patient
appears cachectic on general exam. Laboratory data: Hb 9 g/dL; Hct 27%;
BUN 13 mg/dL; creatinine 0.4 mg/dL; sodium 124 mEq/L; potassium 3.8
mEq/L. Chest x-rays are shown in Fig. 62. An associated symptom that
c.Steady boring chest pain
212Chest Radiology
Mediastinal Compartments213
Description of X-rays in This Chapter
Figure 56.
This PA chest film demonstrates a large superior mediastinal
shadow with marked right displacement of the trachea. There is minimum
thickening of the minor fissure with some small atelectatic streaks on the
roid goiter, a CT scan would be definitive.
Figure 57.
that these opacities are due to enlarged pulmonary arteries, the shape and
Figure 61.
The PA view shows normal lung parenchyma with no acute or
active process. The cardiac size and pulmonary vasculature appear normal.
The descending aortic shadow appears more prominent and there is a dou-
ble density around the aortic arch. On the lateral, there is some haziness in
Mediastinal Compartments
posterior to the posterior margin of the heart and
6 Ts:t
216Chest Radiology
Mediastinal Compartments
The answers are 106-b, 107-c.
this patient and the characteristic CXR are consistent with pulmonary
echocardiogram to estimate PA pressures. Chronic bronchitis is unlikely in
this nonsmoker, and deconditioning would not give the physical signs
observed. There is no clinical or radiographic evidence of mitral stenosis.
PFT and exercise test would be abnormal but nonspecific, and aggressive
exercise programs would be contraindicated.
The answers are 108-d, 109-a.
controlled hypertensive with end organ damage are suggestive of either an
acute coronary event or aortic dissection. The ECG does not show any acute
ischemia or injury pattern. CXR reveals a double shadow in the region of the
218Chest Radiology
220Chest Radiology
Cardiac and Pericardial Disease221
A 67-year-old male smoker was seen in the ER for evaluation of
cough and treated for acute bronchitis. A CXR done at that time prompted
a referral to the chest clinic. The patient gives a past history of myocardial
infarction, but at the moment is asymptomatic. BP is 128/80 and car-
diopulmonary exam is unremarkable. PPD is 7 mm. CXR is shown in Fig.
a.Hypertensive cardiomyopathy
b.Tuberculous pericarditis
c.Epicardial fat pad
d.Left ventricular aneurysm
222Chest Radiology
Cardiac and Pericardial Disease223
224Chest Radiology
A 46-year-old man with history of coronary artery disease is admit-
ted with shortness of breath, paroxysmal nocturnal dyspnea, orthopnea,
and chest discomfort. On exam, he is in severe distress. Lung exam reveals
bilateral crackles. The patient requires immediate intubation and ventila-
tory support. CXR is shown in Fig. 65. Another finding most likely associ-
Cardiac and Pericardial Disease225
A 42-year-old female smoker with a 20-pack-year history is admitted
with progressive shortness of breath. On exam, she has distant heart
sounds with decreased breath sounds on lung exam bilaterally. No sum-
mation gallop is heard. ECG shows low voltage. Chest x-ray is shown in
A procedure is performed for worsening symptoms. The finding on
d.Herniation of the right lung
a.Positional change of chest x-ray findings
b.Pericardial rub on auscultation
c.Hammans crunch on physical exam
d.Continuous diaphragm sign on CXR
Diagnosis of malignancy is established by the above procedure. The
likely primary carcinoma causing this in this patient is
226Chest Radiology
Cardiac and Pericardial Disease227
Cardiac and Pericardial Disease229
230Chest Radiology
Cardiac and Pericardial Disease231
A 48-year-old man is admitted with shortness of breath and signs of
left ventricular failure. CXR is shown in Fig. 68.
a.A diastolic rumble
b.Soft first heart sound
c.Atrial flutter/fibrillation
d.Atrial myxoma
a.Cavitary disease
c.Widened carinal angle
d.Hilar mass
232Chest Radiology
Cardiac and Pericardial Disease233
A 27-year-old woman is admitted with cough, shortness of breath, and
palpitations. She has been relatively well for most of her life, but her
mother gives a history that the patient had recurrent pneumonia as a
child. The patient denies any sputum production. On examination, she
appears anxious. Her neck veins are distended and she has a widened split
second heart sound with little respiratory variation. A systolic ejection
murmur in the pulmonic area is noted. Lung exam reveals bilateral crack-
les; mild ascites and pedal edema are also noted. EKG shows right axis
a.Primary pulmonary hypertension
b.Atrial septal defect
c.Immune deficiency with endocarditis
d.Bronchiectasis sicca
a.CT scan of the chest
b.Immunoglobulin levels
c.PPD testing
234Chest Radiology
Cardiac and Pericardial Disease235
Description of X-rays in This Chapter
Figure 63.
Figure 68.
Cardiac and Pericardial Disease
pericardial effusion as seen on the chest x-ray. The associated finding would
be a low voltage on ECG due to an effusion. Pulsus alternans may also be
seen. The Kussmaul sign is seen with constrictive pericarditis. Left ventricu-
lar hypertrophy and pulmonary edema suggest left ventricular failure. This is
not necessarily associated with cardiac tamponade and pericardial disease.
Left ventricular aneurysm is usually secondary to
myocardial infarction and may calcify. A true aneurysmal dilatation occurs
anterolaterally and may require elective surgery. False aneurysms occur
posteriorly and usually signify a contained rupture, which requires emer-
gent surgical resection. In this case, the chest x-ray and the history of pre-
vious myocardial infarction make option d the best answer.
The clinical history is consistent with left ventric-
ular failure secondary to an acute coronary event. One of the signs of heart
failure is a summation gallop. The chest x-ray is consistent with this diag-
nosis also. Diffusion is increased in congestive heart failure due to decreased
transit time at the alveolar capillary interface; hemoptysis is generally mild
with pink frothy sputum, and clubbing is not present.
The answers are 115-b, 116-a, 117-b.
a pneumopericardium. This refers to the presence of air within the pericar-
dial sac. Pathologically, air can enter the pericardium from the mediastinum
near the pulmonary veins. Air can also develop within the pericardium due
to production by gas-forming organisms in cases of infection. At times the
pneumopericardium may be complicated by the presence of fluid (hydro-
pneumopericardium) or pus (pyopneumopericardium). Closed chest injury
with or without perforation of the pericardium is the most frequent nonsur-
gical cause associated with this kind of pattern. Contiguous organ involve-
ment (pulmonary abscess, bronchogenic carcinoma, esophagitis, perforated
gastric ulcer, foreign body) also can result in the involvement of the peri-
cardium and hence cause pneumopericardium. Septicemia causing direct
seeding of the pericardial space can also produce a common communication
with the lung. With pneumopericardium, the lucent halo of air partially or
immediately shift in location whereas mediastinal air change will not occur.
238Chest Radiology
Thecontinuous diaphragm sign is seen in pneumomediastinum. In this
astinal air present along the diaphragm and below the heart, giving the
appearance of a single continuous diaphragm. Both adults and children can
develop life-threatening cardiac tamponade due to pneumopericardium. A
pericardial rub is a sign of pericarditis and is usually not heard once an effu-
sion develops. The Hamman sign is a crunching noise heard with the apex
beat and heard best in the left lateral decubitus position. It is seen in 50% of
with subcutaneous emphysema in the suprasternal notch. Malignant peri-
cardial effusions are most commonly seen secondary to breast and lung can-
cer, but local spread is commonly due to the latter.
The answers are 118-a, 119-a.
fied pericardium. Asbestosis is defined as respiratory impairment with
interstitial lung disease. Asbestos exposure causes pleural plaques. This is
not seen on the chest x-ray. Tuberculous pericarditis is an unusual mani-
festation of tuberculosis in much of the Western world. Pericardial involve-
ment occurs in 1% to 4% of all patients with tuberculosis. Tuberculosis is
also frequently implicated as a cause of constrictive pericarditis, and the
Kussmaul sign is seen in this disorder. In the United States, tuberculosis
accounts for about one-fifth of cases of chronic constrictive pericarditis.
Tuberculosis accounts for 93% of cases of pericardial effusion in patients
coinfected with HIV. There are four stages in the evolution of tuberculous
pericarditis. Initially there is a fibrous stage in which the diffused deposits
Cardiac and Pericardial Disease
size may be normal in acute myocardial infarction or acute valvular dysfunc-
240Chest Radiology
242Chest Radiology
246Chest Radiology
250Chest Radiology
A 68-year-old female smoker is seen in the ER due to mild hemoptysis
and cough with 1 to 2 teaspoons of light-green sputum production in the
.She uses inhalers as needed for occasional shortness of breath. A rou-
a.Asbestos exposure
b.Old TB with thoracoplasty
c.Lung cancer
d.Chronic bronchitis
a.Ferruginous bodies
b.Malignant cells
c.Acid-fast bacilli
d.Charcot-Leyden crystals
252Chest Radiology
ing ribs are involved. Infections as well as tumors may involve the chest
wall and the surrounding tissue. Chest wall lesions account for 2% of all
primary tumors; primary soft tissue tumors are more common than pri-
mary bony tumors. Bronchogenic tumors may involve the chest wall by
direct extension with infiltration of the surrounding tissue.
The answers are 125-c, 126-b, 127-a.
When rib fractures are
present, patients usually experience pain. When several ribs are fractured,
the respiratory status may become compromised.
inspiration, when the thorax normally expands in all directions, the negative
intrapleural pressures will cause the unstable portion of the chest wall to
draw in. Similarly, on expiration, the unstable portion of the chest wall
moves outward. This results in diminished effectiveness of breathing, and the
pain from rib fracture may lead to splinting of the chest wall, thus impairing
ventilation. Complications such as atelectasis and pulmonary infections can
occur. If large areas of the chest wall are unstable, mechanical ventilation may
be considered, as this provides a form of internal fixation of the chest wall.
Chronic residual effects of flail chest are uncommon. Rib fractures are a com-
mon result of chest trauma, and a chest radiograph is needed as a follow-up
for complications of these fractures such as pneumothorax, atelectasis, or
pneumonia. Intercostal nerve blocks provide substantial relief of pain.
The answers are 128-a, 129-b, 130-a.
combination of excessive anterior and posterior lateral curvature of the tho-
racic spine. The abnormal curvature may be laterally dominant as a scoliosis
or posteriorly as kyphosis. Deformity of a sufficient degree leads to symp-
toms and signs referable to the lungs and heart. This occurs in less than 3%
of those with abnormal curvature. About 80% of cases of scoliosis are idio-
pathic, with no clear cause identified. The disease is classified into three
pulmonary artery hypertension, cor pulmonale, and chronic respiratory fail-
ure. Pulmonary hypertension is due to chronic hypoxemia, which is sec-
ondary to V/Q mismatch. Restrictive lung defect is seen on pulmonary
function tests, and diffusion abnormality is uncommon. Manipulations of the
256Chest Radiology
258Chest Radiology
Diaphragmatic Lesions259
Diaphragmatic Lesions261
A 40-year-old woman is referred for evaluation of a mass seen on a
chest x-ray. Chest x-rays (Fig. 75) are shown below.
a.Bronchogenic cyst
b.Hernia through the foramen of Bochdalek
c.Hydatid cyst
d.Loculated pleural effusion
a.Is more common on the left
b.Is usually associated with severe symptoms
c.Requires immediate surgery
d.Cannot be confirmed by a barium swallow
262Chest Radiology
Diaphragmatic Lesions263
264Chest Radiology
Diaphragmatic Lesions265
Description of X-rays in This Chapter
Figure 74.
This chest x-ray shows a large, air-containing, hyperlucent
opacity in the middle portion of the thorax representing a large hernia in
The symptoms described are due to an acid reflux
disorder, and the chest x-ray shows a large hiatal hernia. Hiatal hernia rep-
resents herniation of the stomach through the esophageal hiatus and is fre-
Diaphragmatic Lesions
are asymptomatic, some may complain of respiratory or epigastric pres-
sure or pain.
The answers are 139-d, 140-a.
hemidiaphragm can be seen as a result of an enlargement or displacement
of an abdominal organ, a subpulmonic process such as effusion, loss of vol-
ume of the lung with lobar atelectasis or surgical resection, or hemidia-
phragmatic paralysis. Diaphragmatic paralysis results from interruption of
the phrenic nerve supply to the diaphragm. The most common cause is
malignancy, such as bronchogenic carcinoma, or postsurgical trauma.
Twenty percent of patients who undergo open heart surgery sustain injury
to the phrenic nerve. Other causes of diaphragmatic paralysis include
polio, herpes, infections, lead poisoning, pulmonary infarctions, pneumo-
nia, mediastinitis, and pericarditis. The diagnosis of unilateral paralysis of
on the chest x-ray. With diaphragmatic paralysis, the negative pleural pres-
sure tends to pull the paralyzed diaphragm upward. Normally the right
matic paralysis is established by the sniff test. In this test the diaphragm is
observed fluoroscopically as the patient sniffs. The normal diaphragm is
moved downward during the sniff maneuver as the diaphragmatic muscles
contract. A paralyzed diaphragm moves paradoxically upward because of
negative pleural pressure. Patients with paralyzed diaphragms may be
268Chest Radiology
270Chest Radiology
Lines/Devices/Complications in ICU271
A 40-year-old woman admitted with fever, chills, and changing men-
tal status is transferred to the ICU with a clinical suspicion of sepsis. Exam-
ination shows sinus tachycardia, no murmur, and clear lung fields. The
patient is given IV fluids aggressively for hydration. Blood cultures are
given for thromboembolic prophylaxis. As the patient does not improve
satisfactorily, a procedure is performed. One hour after this procedure, the
a.Silent unrecognized mitral stenosis
b.Acute pulmonary edema
c.Complication of heparin therapy
d.Pulmonary infarction
a.Perform an urgent echocardiogram
b.Administer protamine sulfate
c.Start inotropic agents
272Chest Radiology
Lines/Devices/Complications in ICU273
A 43-year-old man with a history of substance abuse is admitted to the
ICU with status asthmaticus and respiratory failure. Upon reaching the
ICU, he has a cardiorespiratory arrest and requires CPR, intubation, and
CPR it remains at 80/60 mm Hg. An immediate IV fluid bolus is adminis-
tered and a CXR (Fig. 79) is done.
What is a possible cause of the patients persistent hypotension?
b.Severe status asthmaticus
c.Tension pneumothorax
d.Pulmonary embolism
Physical exam on the affected side will most likely reveal
a.Pleural friction rub
b.Severe wheezing
c.Area of egophony
d.Absent breath sounds
a.Discontinuation of mechanical ventilation
b.Anticoagulant therapy
c.Chest tube placement
d.Inotropic agents
274Chest Radiology
Lines/Devices/Complications in ICU275
A 36-year-old woman with a history of obstructive sleep apnea is
admitted with acute shortness of breath, cough with greenish sputum, and
fever. On physical examination, she is febrile and has decreased breath
sounds generally and diffuse bilateral rhonchi. ABGs: pH 7.32; P
Initial treatments should include all except
agonist aerosol Rx
d.IV theophylline
The patient improves initially but has a respiratory arrest as she is
being moved to the ICU, requiring emergency endotracheal intubation.
While a CXR is ordered, it is noted that she has absent breath sounds on
a.Left pneumothorax
b.Pneumomediastinum with esophageal rupture
c.Left pleural effusion
a.Surgical consult
b.Pleural tap
c.Repositioning of the endotracheal tube
d.Chest tube placement
276Chest Radiology
Lines/Devices/Complications in ICU277
Description of X-rays in This Chapter
Figure 77.
fibromuscular bundles of the neck and chest musculature. There is a faint
paracardiac hyperlucent line representing air around the pericardium. The
of monitoring and life support devices. The physician needs to be aware of
Lines/Devices/Complications in ICU
The answers are 143-d, 144-d.
The patient presents with
280Chest Radiology
282Chest Radiology
Pediatric Cases283
A 4-year-old girl is brought to the ER with a 2-day history of cough
and upper respiratory tract symptoms. Examination reveals bilateral otitis
a.Respiratory syncytial virus
b.Normal variant
d.Primary tuberculosis
The correct statement regarding this chest x-ray finding is
a.It increases with age.
b.Chemotherapy for lymphoma may cause an increase in its size.
c.Carcinoma is common.
284Chest Radiology
Pediatric Cases285
A 2-year-old is admitted with fever, cough, and bilateral earache. On
286Chest Radiology
Pediatric Cases287
Description of X-rays in This Chapter
Figure 81.
opacity with air bronchogram. The diaphragm is clear and the right heart
The answers are 151-c, 152-a.
With a family history of
tuberculosis in a close household contact, the likelihood of the patients
illness being active primary TB is very high. Thirty percent of persons
increased in children under the age of 4 years. About 5% of persons with
recent contact may develop active disease. Most children infected with
Mycobacterium tuberculosis
are asymptomatic and their chest x-rays may
be normal on initial examination. The most common radiographic pre-
sentations in children include hilar and mediastinal lymphadenopathy,
segmental lobar infiltrates with consolidation, or pleural effusion or mil-
iary TB. Extrapulmonary tuberculosis occurs in approximately 20% of
infants and children with TB. Early involvement may include bone and
miliary TB, but later manifestations may include mastoiditis, otorrhea, or
pyrexia of chronic duration.
The answers are 153-b, 154-b.
Pediatric Cases
most likely due to respiratory syncytial virus in this age group. The treat-
ment of choice is aerosolized ribavirin. The chest x-ray shows air trapping.
Respiratory syncytial virus is a single-strand RNA virus that spreads through
self-inoculation with fomites. Outbreaks occur in winter and spring, and
290Chest Radiology
Lung Transplant Patients293
a.Posttransplant lymphomatoid disorder (PTLD)
b.Squamous cell carcinoma
d.Phantom tumor or pseudotumor
a.Diurectic therapy
c.Needle biopsy
294Chest Radiology
Lung Transplant Patients295
A 25-year-old man from Mississippi, with a history of cystic fibrosis
diagnosed at birth, received a bilateral lung transplant 3 years ago. Due to
posttransplant chronic rejection, he underwent a second lung transplant 1
year ago and required intensive antirejection therapy. He now presents
tachypneic with diffuse rhonchi and wheezing, especially in the right
upper lung field. In spite of empirical antibiotic therapy, he does not
improve. A needle biopsy of the lesion seen on the chest x-ray (Fig. 85) is
a.Nocardia infection
c.Cytomegalovirus infection
The treatment of choice in this case is
a.Stopping antirejection drugs
b.Starting amphotericin
c.Stopping antirejection drugs and starting itraconazole
d.Starting gancycolvir
296Chest Radiology
Lung Transplant Patients297
Description of X-rays in This Chapter
Figure 84.
The PA view shows a rounded opacity in the right lower zone.
The horizontal fissure is seen distinctly through and separate from this
opacity, suggesting that this is not a pseudotumor, i.e., fluid in the fissure.
carinal area. A band of linear atelectasis is seen in the right lower zone. The
lateral confirms that the rounded opacity is in the hilar area and the mid-
dle mediastinum, unrelated to the horizontal fissure.
Figure 85.
This chest x-ray shows diffuse disease. Overall, the pattern is
of confluent nodularity and coalescence. These opacities are seen in the left
lower zone, where they are peripherally located. Similarly, a right para-
the right lung. Poststernotomy sutures and clamps and an IV access line
leading to the PA are also noted. A small pneumothorax is present on the
Lung transplantations are performed primarily for the treatment of pul-
monary fibrosis, primary pulmonary hypertension, cystic fibrosis, and
end-stage emphysema. Bilateral lung transplantation is preferred in young
patients or in cystic fibrosis, where there is an increased risk of donor lung
infection from the native lung. Five-year survival is about 50% to 60%.
Immediate causes of morbidity and mortality include reperfusion injury,
airway injury and ischemia, acute rejection, and infection. Acute rejection
is graded by the severity of perivascular infiltration, ranging from minimal
to severe. Acute rejection can occur due to subtherapeutic cyclosporin
pneumonia recurs in the perioperative period and presents with pneu-
infections, bronchiectasis, and airway stenosis. Causes of death after the
initial postoperative and hospital course include chronic rejection, bron-
chiolitis obliterans, sepsis, and lymphoproliferative disease. The imaging
techniques used in evaluating patients with immune-compromised states
begin with a chest x-ray. Although these abnormalities are nonspecific, they
are helpful in assessment when viewed in conjunction with other clinical
data such as the time of development of the changes. Three primary pat-
terns are generally seen. These are a diffuse interstitial pattern, nodular
opacities, and areas of consolidation. Cavitary opacities are seen in necro-
tizing infections such as those caused by anaerobes and aspergillus. Radio-
graphically, nodular opacities in the transplant patient are due to
aspergillus, rhodococcus, posttransplantation lymphoproliferative disorder
The answers are 157-a, 158-c.
plantation lymphoproliferative disorder (PTLD) confirmed by a needle
biopsy. The incidence of PTLD in lung transplant recipients is approxi-
mately 2% to 5% and is higher than in other solid organ transplants. It is
closely associated with Epstein-Barr virus infection, and children are more
prone to develop this disorder. The majority of PTLDs are non-Hodgkins
lymphomas and B-cell tumors. Typical radiographic features include mul-
tiple nodules, mediastinal adenopathy, airspace disease, and pleural effu-
Lung Transplant Patients
infections are less common but are associated with higher mortality. In-
vasive aspergillosis manifests as pneumonia with airspace consolidation.
This patient had signs of airway and airspace disease, and, given his history
of intense immunosuppression, aspergillus infection is the most likely
300Chest Radiology
Acinar pattern.
A collection of round, patchy, or confluent opacities pro-
ducing an inhomogeneous shadow, representing one or more ana-
tomic acinar structures rendered opaque by consolidation. The acinus
is a portion of lung parenchyma that is distal to the terminal bron-
chiole and consists of the respiratory bronchiole, alveolar sacs, and
Air bronchiologram.
A peripherally located air bronchogram. Air is seen
in a bronchus, implying a patent airway.
Air bronchogram.
A shadow of an air-containing bronchus peripheral to
the hilum and surrounded by airless consolidation.
Air-fluid level.
horizontal x-ray beam, creates a shadow characterized by a sharp hor-
i.e., airless segment or lobe, with corresponding loss of volume. Used
the frontal x-ray and bears a resemblance to a bat in flight, and is said
Ground glass pattern.
Alveolar-arterial difference of oxygen
ABGsArterial blood gases
ACEAngiotensin converting enzyme
AFBAcid-fast bacilli
ANAAntinuclear antibody
ARDSAdult respiratory distress syndrome
PFTsPulmonary function tests
Partial pressure of oxygen
PPDPurified protein derivative (TB skin test)
PTHParathyroid hormone
RVResidual volume
SPNSolitary pulmonary nodule
TLCTotal lung capacity
WBCWhite blood cell
For each chapter, you will find the appropriate clinical findings and
matched radiographic differential diagnoses. Refer to chest x-rays and
Clinical Key
Chapteror HintsDiagnosisFiguresQuestions
1.Solitary PulmonaryEndemic areaCocci1417
NodulePositive PPDGranuloma
2.Multiple PulmonaryLow-grade feverMiliary disease58814
Clinical Key
Chapteror HintsDiagnosisFiguresQuestions
InfertilityImmotile cilia
RepeatedSequestration of
Cough/repeated Cystic fibrosis
7.Diffuse Interstitial Clubbing,Idiopathic 25304455
Shortness ofSarcoidosis
Shortness of BOOP
Shortness of Hypersensitivity
Shortness of Lymphangitic
8.Diffuse Airspace HemoptysisAlveolar 31345659
Increased ARDS
Sputum/non-res Bronchoalveolar
Difficulty Aspiration
9.Focal Airspace Endobronchial RUL atelectasis35386068
OpacitiesLLL mass on LLL sail sign
Horner Pancoast tumor
Mucus plugRUL atelectasis
10.Focal Airspace Fever, chillsMultilobar 39426977
OpacitiesFever, chillsLLL pneumonia
Fever/hx of Klebsiella
308Quick Reference
Clinical Key
Chapteror HintsDiagnosisFiguresQuestions
11.Unilateral Transmitted Pneumonectomy43457880
Quick Reference309
Clinical Key
Chapteror HintsDiagnosisFiguresQuestions
16.Chest Wall and HX MVARib fractures7073125135
310Quick Reference

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