Case 8 Active Pulmonary Tuberculosis
The CXR shows bilateral upper lobe infiltrates with cavities, suggestive of active pulmonary tuberculosis. In general, thin-walled cavities lt 5 mm tend to be infective and, when thick-walled gt 10 mm , squamous cell carcinoma of the lung enters into the differential diagnosis. Tuberculosis tends to afflict the upper lobes and apical segment of the lower lobes. However, within the upper lobe, anterior segment involvement is rare. Diagnosis is confirmed by obtaining sputum and staining with...
Case 20 Cardiac Tamponade From Massive Pericardial Effusion
Beck described a triad of hypotension, muffled heart sounds, and elevated jugular venous pressure due to cardiac tamponade from pericardial effusion. Immediate pericardiocentesis is life-saving. The common causes of pericardial effusion include malignancy, congestive heart failure, tuberculosis, systemic lupus erythe-matosus, Dressler's syndrome, and uremia. This CXR shows a globular enlargement of the heart, typical of a large pericardial effusion. In addition, there is a mass in the right...
Case 12 Dissecting Thoracic Aneurysm
The CXR shows widening of the superior mediastinum and a well-defined mass inferior and contiguous with the arch of the aorta. In this clinical context, dissection of the arch of the aorta has to be excluded. CT Thorax in another patient shows the presence of an aneurysm Fig. 12.2 at the aortic arch with thrombus. Case 13. This 80-year-old male smoker is a known case of COPD. He presented with epigastric pain and worsening of shortness of breath. Arterial blood gas showed acute metabolic...
Case 4 Congestive Heart Failure
The CXR shows classic evidence of left ventricular failure, i.e. cardiomegaly car-diothoracic ratio gt 50 , upper lobe pulmonary venous diversion, and Kerley B lines which indicate distension of lymphatics . In addition, there is evidence of sternotomy wires, suggesting previous coronary artery bypass surgery CABG . Following diuresis, the pulmonary infiltrates have cleared Fig. 4.2 . Only fluid and blood on the chest radiograph can clear rapidly within days . This patient also has a right...
Case 42 Malignant Mesothelioma
The CXR shows a small left pleural effusion with blunting of the left costophrenic angle. The left hemithorax is smaller than the right. The mediastinum is also widened due to tumor creeping along the pleura. All these are features of malignant mesothelioma, which is a primary malignancy of the pleura and typically spreads along the pleura as demonstrated on CT Fig. 42.2 . Case 43. This patient was asymptomatic. This was his CXR Fig. 43.1 . Case 43. This patient was asymptomatic. This was his...
Case 73 Carcinoma Of Esophagus
The CXR shows a dilated esophagus behind the heart with an air-fluid level in the region of the carina. This is indicative of an obstruction at the esophagus and possibilities include carcinoma of the esophagus, benign stricture, achalasia, and scleroderma. The CT Thorax Fig. 73.2 shows the esophageal carcinoma more clearly at the level of the carina. Fig. 73.3 shows a similar patient who has had an esophageal stent Ultraflex placed for palliation of dysphagia. Case 74. This 70-year-old female...
Case 95 Lung Abscess
See Case 8. The CXR shows a cavitary lesion at the right hilum Fig. 95.2 . Lateral X-ray Fig. 95.3 shows the lesion to be thin walled and at the apical segment of the right lower lobe. The causes of lung cavities include primary lung cancer typically Squamous cell , tuberculosis, Klebsiella, Staphylococcus aureus usually multiple , anaerobes, mycetoma, Wegener's granulomatosis, rheumatoid nodule, and pulmonary infarction. Lesions in the upper lobe and apical segment of the lower lobes are...
Case 93 Fractured Left Scapula
The CXR shows an obvious fracture of the body of the left scapula Fig. 93.2 which usually results from severe trauma. Fracture of the scapula is rare as the overlying muscles provide some protection. The left hemidiaphragm is elevated because of splinting due to pain. Case 94. This patient was admitted following an accident in which a heavy overhead object fell on him. The CXR is shown Fig. 94.1 .
Case 14 Calcified Left Ventricular Aneurysm
The PA and lateral CXR confirm an arcuate density in the region of the left ventricle. This is typical of calcification of a left ventricular aneurysm, usually secondary to previous myocardial infarction. Surgical resection of the aneurysm is potentially curative. Case 15. A 60-year-old male presented with exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and bilateral painless ankle swelling. This was his CXR Fig. 15.1 . What is the abnormality and subsequent management
Case 84 Bilateral Pleural Effusions Due To Intraabdominal Malignancy And
The CXR shows both costophrenic angles being blunted suggesting bilateral pleural effusions. The heart size is normal. In situations of bilateral pleural effusion, one must think in terms of a transudative state, e.g. congestive heart failure, nephrotic syndrome, or liver cirrhosis. If the fluid is exudative, an intraabdominal process has to be ruled out. In the CXR shown, another important finding is the small lung volumes, which may suggest an intra-abdominal process, e.g. malignant ascites...
Case 71 Mediastinitis
There is a right-sided pleural effusion and, in addition, an air-fluid level is noted behind the right side of the heart Fig. 71.2 . This is typical of a perforated esophagus Boerhaave's Syndrome due to a full thickness laceration leading to media-stinitis from vomiting resulting in free air in the mediastinum and a pleural effusion. This patient had food particles at tube thoracostomy. CT scan shows the right hydropneumothorax due to the resultant empyema Fig. 71.3 . Case 72. This elderly male...
Case 80 Copd With Bullae
In addition to features of hyperinflation Case 19 , the CXR also shows right lung hyperlucency. This could be due to two possibilities, pulmonary embolus or bulla. Right pneumothorax is unlikely because of the absence of a pleural line. CT Fig. 80.2 demonstrates the presence of a giant right upper lobe bulla, a complication of COPD. One must be careful to make this differentiation, as tube thoracostomy in a patient with a bulla can be disastrous. Case 81. This middle-aged male of Japanese...
Case 74 Right Upper Zone Opacity Due To Retrosternal Goiter
The CXR shows a shadow in the right upper zone distending the right paratracheal stripe. The shadow has a sharp curvilinear lateral border Fig. 74.2 and seems to extend to the neck. The trachea is also displaced to the left. Such a shadow at this location is typical of retrosternal goiter and this is confirmed on the CT Fig. 74.3 . Case 75. This patient was asymptomatic. His CXR is shown Fig. 75.1 .
Case 44 Anomalous Pulmonary Venous Drainage Scimitar Sign
The curvilinear shadow in the right lower zone is called a Scimitar sign. This is due to aberrant drainage of the right inferior pulmonary vein Fig. 44.2 into the inferior vena cava. This is a congenital anomaly and is usually associated with a small ipsi-lateral hemithorax and a small or hypoplastic pulmonary artery. This condition is usually of no clinical significance. The CT scan shows the enhancing vein Fig. 44.3 . Case 45. This middle-aged female complained of hemoptysis and loss of...
Case 87 Radiation Fibrosis Of Right Upper Lobe
The CXR shows volume loss in the right hemithorax in keeping with previous right middle and lower lobectomy for cancer. The infiltrates in the upper zone are due to radiation fibrosis and the sharp margin Fig. 87.2 delineates the limits of lung shielding during the radiotherapy. Case 88. This patient is asymptomatic. The CXR is shown Fig. 88.1 .
Case 36 Mediastinal Lymphadenopathy Due To Lymphoma
See Case 11. The CXR shows asymmetric distortion of the mediastinal contour by markedly enlarged lymph nodes overlying the left hilum. This is described as the hilar overlay sign - the normal left pulmonary artery Fig. 36.2 is seen through the mass lying at the anterior mediastinum . Other differential diagnoses include chronic lymphocytic leukemia, sarcoidosis, Castleman's disease, and granulomatous disease like tuberculosis or histoplasmosis. The histology from mediastinoscopy in this patient...
Case 98 Posterior Mediastinal Mass
The CXR shows a well-circumscribed shadow behind the heart abutting the vertebral body and aortic arch Fig. 98.2 localizing it to the posterior mediastinum. The commonest cause of posterior mediastinal masses are of neurogenic origin, e.g. neurofibroma, neurilemma, ganglioneuroma. Other less common causes include meningocele, extramedullary hemopoiesis, esophageal cysts, and aortic aneurysms. MRI Fig. 98.3 confirms the presence of the neurogenic tumor.
Case 11 Bilateral Hilar And Mediastinal Adenopathy From Sarcoidosis
CXR shows bilateral symmetrically enlarged hilar and mediastinal lymph nodes. CT Fig. 11.2 confirms this finding, typical of sarcoidosis. The main differential diagnoses would be lymphoma and tuberculosis, but the lymphadenopathy would then be asymmetrical. Bronchoscopy and transbronchial lung biopsy are positive in 60 of cases, showing non-caseating granulomas and culture negative for tuberculosis and fungus. Blind endobronchial biopsies increase the yield by another 20 but the gold standard...
Case 5 Foreign Body Right Lower Zone
The CXR shows an opaque density in the region of the right lower zone Fig. 5.2 . Each lung field on an erect CXR is divided into three zones. The upper zone is an area which lies above a horizontal line drawn from the medial end of the second rib anteriorly. The middle zone lies below this and is bordered inferiorly by a line drawn similarly from the fourth rib. The lower zone lies below this. This opaque density is similar in configuration to a tooth which was dislodged during emergency...
Case 25 Malpositioned Nasogastric Tube
The tip of the nasogastric tube should be seen within the gastric bubble. In this case, the tube has coiled at the esophageal cardia and ended up in the mid-esophagus Fig. 25.2 . Feeding within the esophagus may result in fatal aspiration. The CXR also shows evidence of right lower lobe infiltrates, a typical site for aspiration pneumonia. Case 26. This was a routine CXR Fig. 26.1 taken after placement of a subclavian central venous catheter.
Case 83 Mass Behind Right Heart Border Due To Sequestrated Lung
There is a mass seen along the right heart border. The fact that the margin of the heart is not silhouetted out implies that the mass is likely to be in the posterior mediastinum the heart is an anterior structure , making lung cancer unlikely. CT Fig. 83.2 confirmed the presence of the mass and, in addition, blood vessels are seen arising from the descending aorta making the diagnosis of sequestrated lung likely. This is a congenital abnormality where the non-functioning lung tissue is...
Case 79 Right Cervical Rib
The CXR shows a right accessory rib, which is arising from the seventh cervical vertebra Fig. 79.2 . This condition is present in 1 of the population with 80 of cases being bilateral. Rarely, this condition may be symptomatic due to pressure on the lower trunk of the brachial plexus. Case 80. This elderly male chronic smoker had a five-year history of productive cough and exertional dyspnea. His CXR is shown Fig. 80.1 .
Case 61 Tracheal Stenosis Due To Tracheopathia Osteochondroplastica
The CXR shows narrowing of the tracheal air column Fig. 61.2 with calcification of the wall. Tracheal narrowing can be due to malignant causes lung cancer, lymphoma, metastases or benign causes post tuberculosis, posttraumatic, amyloidosis, sarcoidosis, Wegener's, Tracheopathia Osteochondroplastica . Tracheopathia Osteochondroplastica TO is an extremely rare condition, characterized by the presence of multiple osseous and or cartilaginous submucosal nodules Fig. 61.3 protruding into the lumen...
Case 26 Malpositioned Right Central Venous Catheter
The most obvious abnormality is that the right subclavian central venous catheter tip has curled upwards into the right internal jugular vein instead of downwards into the superior vena cava. The other finding is that of soft tissue swelling in the right neck and superior mediastinal widening. This patient had severe coagulop-athy and repeated attempts at the central venous catheter insertion resulted in a neck hematoma which had also tracked inferiorly causing a mediastinal hematoma. As a...
Case 40 Mass In Right Lung Arising From Trachea And Right Bronchial Tree
The CXR shows a mass in the right upper zone with a pleural effusion, suggestive of advanced lung cancer. The lower end of the tracheal air column also shows narrowing, indicating involvement by the cancer. Lung cancer is the commonest cause of malignant pleural effusion and is usually secondary to smoking. Squamous cell and small cell lung cancer tend to involve the central airways, the latter often associated with mediastinal lymphadenopathy. Adenocarcinoma of the lung tends to present as...
Case 43 Rightsided Aortic Arch
The aortic knuckle, which is usually on the left, is now on the right Fig. 43.2 . This is a congenital abnormality. The commonest type is associated with an aberrant anterior left common carotid artery and a retroesophageal left subclavian artery. This is seen in about 1 in 2500 patients and is not associated with any congenital heart disease. Case 44. This patient was asymptomatic. The CXR is shown Fig. 44.1 . Case 44. This patient was asymptomatic. The CXR is shown Fig. 44.1 .
Case 17 Mycetoma Right Upper Lobe
The CXR shows a right upper lobe ball within a cavity air crescent sign patho-gmonic of a mycetoma also called aspergilloma . A lateral decubitus X-ray may demonstrate the fungal ball shifting position. In this condition, a preformed cavity becomes colonized, usually by the fungus Aspergillus fumigatus. Cavitary disease may be secondary to fibrotic lung disease, e.g. previous tuberculosis, sarcoidosis, or ankylosing spondylitis. Massive hemoptysis can result and bronchial angiogram with...
Case 39 Bamboo Spine Appearance Due To Ankylosing Spondylitis
The most obvious finding is calcification of the interspinous ligaments causing a bamboo spine appearance on CXR, typical of ankylosing spondylitis. This disorder typically affects young males with predominant involvement of the axial spine and the sacroiliac joints Fig. 39.2 . Upper lobe fibrosis may also result. The lung function abnormality that results is usually restrictive. There is a very strong association with HLA-B27. Case 40. This middle-aged female smoker had hemoptysis and loss of...
Case 32 Primary Pulmonary Hypertension
This patient fits the typical clinical and radiological profile of a patient with primary pulmonary hypertension. The pulmonary arteries are markedly enlarged with the right atrial chamber also enlarged. The normal right pulmonary descending artery diameter is less than 16 mm in males and 15 mm in females. The lung fields are clear and the lung volumes normal making lung disease causing pulmonary hypertension unlikely. Other causes to be ruled out are congenital heart disease and chronic...
Case 55 Previous Right Thoracoplasty
Prior to the advent of effective anti-tuberculous drugs, surgery was the only treatment available for patients with tuberculosis. The objective was to cause closure of the upper lobe cavities and one option was thoracoplasty which involves resection of the upper ribs, resulting in lung collapse. In this CXR, the right upper chest is deformed and the pleural space is calcified. Other procedures performed include artificial pneumothorax, phrenic nerve crush, or plombage. Case 56. This middle-aged...
Case 81 Bilateral Small Ring Shadows Diffuse Panbronchiolitis
The CXR shows bilateral diffuse shadows, which appear ring-like with tram-lining of the airways best seen behind the heart . In some areas they may appear nodular. The long duration makes metastatic cancer unlikely. High resolution CT Thorax Fig. 81.2 shows thickened bronchi and bronchioles. The small peripheral airways have a tree-in-bud appearance due to mucoid impaction of the small airways consistent with the diagnosis of diffuse panbronchiolitis. This condition was first described by the...
Case 22 Severe Pneumonia
See Case 1. The CXR shows opacities with air bronchograms involving both lung fields. This is typical of severe pneumonia as evidenced by multilobar involvement. Typical organisms include Streptococcus pneumoniae, Legionella, and gram negatives like Klebsiella and Pseudomonas aeroginosa. In South-East Asia, another possible etiologic agent is Burholderia pseudomallei Meliodosis . Treatment will require combination parenteral antibiotics, usually beta lactams plus macrolide or fluoroquinolone....
Case 57 Right Subpulmonic Effusion
The CXR shows that the right costophrenic angle is blunted suggestive of a small pleural effusion. In addition, the right hemidiaphragm has its highest point displaced laterally. Normally the dome of the hemidiaphragm should have its highest point medial to the midpoint between the midline and the chest wall. These are clues to the fact that there is fluid trapped in the space between the right hemidiaphragm and the inferior aspect of the lung. Case 58. This elderly patient is asymptomatic. He...
Case 33 Traumatic Aortic Disruption
This CXR shows evidence of a widened superior mediastinum and loss of the aortic knuckle and obliteration of the aorto-pulmonary window. There is left apical capping as a result of mediastinal blood tracking to the extrapleural region of the left hemithorax. The trachea is deviated to the right and the left main-stem bronchus is depressed. The fifth and sixth ribs on the left side are fractured. Sometimes there is an associated left hemothorax. All these are typical features of traumatic aortic...
Case 1 Pneumonia
The CXR shows a focal shadow in the right lower lobe with air bronchograms suggestive of pneumonia. It is clearly in the right lower lobe because the right hemidi-aphragm is effaced. Right middle lobe shadows would efface the right heart border. The presence of air bronchograms indicates pathology in the alveoli, as the conducting airways remain patent with air. Water or blood can also occupy the alveoli as a result of pulmonary edema or pulmonary hemorrhage respectively. There should be other...
Case 7 Azygous Lobe
There is a curvilinear density adjacent to the right superior mediastinum with an ovoid lower density at its lower end the azygous vein . The azygous lobe is the commonest CXR normal variant seen in up to 0.4 of individuals. This is an embryologic variation which results in an accessory lobe at the right upper lobe. The fissure Fig. 7.2 is due to the invagination of the azygous vein and the condition is of no clinical significance. Case 8. This was an 80-year-old male with fever, productive...
Case 60 Right Tension Pneumothorax
See Case 2. The CXR shows that the endotracheal tube is too far down and the tip is now sitting at the origin of the right main-stem bronchus. The ideal position is for the tip of the tube to be at the level of the clavicles. This patient also had a right central venous catheter inserted. The tip of the central venous catheter should ideally lie at the junction of the superior vena cava and the right atrium. The other important finding is that of a lucent area at the anterior costophrenic...
Case 53 Idiopathic Pulmonary Fibrosis
The CXR shows small bilateral lung volumes. There are basal infiltrates which are peripheral and cystic in appearance, not unlike a honeycomb. These changes are better demonstrated on the CT Fig. 53.2 . This is the typical appearance of Idiopathic Pulmonary Fibrosis also known as Cryptogenic Fibrosing Alveolitis . The typical profile is a middle-aged female with shortness of breath over months. It can be associated with connective tissue diseases like rheumatoid arthritis and systemic lupus...
Case 68 Left Pleural Effusion And Lytic Lesion In The Left Third Rib Suggestive
The CXR shows a moderate-sized left pleural effusion, which is loculated. There is also globular cardiomegaly, suggesting a pericardial effusion. Pleural tap showed malignant cells consistent with the diagnosis of adenocarcinoma of the lung. In addition, the second, third, and fourth ribs on the left side Fig. 68.2 demonstrate lytic lesions in keeping with bony metastases. Bone scan would be helpful in confirming the bone metastases. These are all features of advanced lung cancer with...
Case 50 Metastases To Lungs
See Case 46. The CXR shows bilateral peripheral lung nodules of varying sizes and this is better demonstrated on the CT Fig. 50.2 . This appearance is typical of lung metastases. The basal predominance is due to the greater blood supply in the lung bases. Lung metastases can arise from cancers of the breast, colon, rectum, and kidney. Case 51. This female patient was asymptomatic. Her CXR is shown Fig. 51.1 .
Case 3 Ruptured Liver Abscess
It is important to look at the blind areas of the CXR in order not to miss important clues. These areas are under the diaphragm, behind the heart, the hilum, and the soft tissues. This CXR shows a lucency over the liver density. The lucency does not conform to the usual bowel configuration. In this clinical context, an important differential diagnosis to be considered is a ruptured liver abscess. This can be confirmed either by bedside ultrasound or CT Fig. 3.2 . Liver abscesses are usually due...
Case 69 Left Lower Lobe Collapse
There is volume loss in the left lung as indicated by an elevation of the left hemi-diaphragm and shift of mediastinum to the left. The left hemithorax is also smaller than the right. In addition, the left hemidiaphragm is obscured indicating a left lower lobe collapse. At bronchoscopy, she was found to have a benign stricture of the left lower lobe orifice Fig. 69.2 from previous tuberculosis. Case 70. This 35-year-old female had a long history of chronic productive cough. Her CXR is shown...
Case 34 Bronchiectasis Affecting Both Lower Lobes
The CXR shows infiltrates especially in the right middle lobe and the left lower lobe. The ring shadows and tramlines indicate the presence of dilated and thickened airways. The CXR findings were noted a few years previously indicating its chronicity. The accepted modality for the diagnosis of bronchiectasis is a highresolution CT Thorax which demonstrates these dilated airways in the left lower lobe Fig. 34.2 using very thin 1-2 mm slices. Bronchography is now seldom used. Case 35. This...
Case 37 Bilateral Calcified Pleural Plaques Due To Asbestos Exposure
The CXR shows bilateral calcified pleural plaques, especially over the diaphragmatic pleura. The mid-zones show en face calcification holly leaf sign . This is typical of asbestos exposure. Previously asbestos was commonly used as an insulating material. Asbestos exposure can also result in benign pleural effusion, round atelectasis, pulmonary fibrosis asbestosis , or malignant mesothelioma. Differential diagnosis of pleural calcification includes previous hemothorax, empyema, and tuberculosis....
Case 13 Pneumoperitoneum Due To Perforated Peptic Ulcer
The CXR shows free air under the right hemidiaphragm, in addition to features of hyperinflation. The possibilities include perforated peptic ulcer or GI malignancy, recent laparoscopy laparotomy, and peritoneal dialysis. It is important to do an erect CXR for the free air to rise to the top of the abdomen. For patients with a nasogastric tube in place, instillation of 200 ml of free air before the CXR may aid the diagnosis. Case 14. This 75-year-old male had a history of myocardial infarction...
Case 9 Silicosis
The CXR shows bilateral infiltrates and calcified nodules in both upper lobes. Differential diagnoses of upper lobe infiltrates include silicosis, tuberculosis, and ankylosing spondylitis. There is also egg-shell calcification of the hilar lymph nodes. The egg-shell calcification plus the upper lobe nodules are typical of silicosis. Differential diagnoses of egg-shell calcification include sarcoidosis, Hodgkin's lymphoma following radiotherapy, and coal-worker's pneumoconiosis. Case 10. This...
Case 75 Eventration Of Right Hemidiaphragm
The CXR shows that the right hemidiaphragm has a hump Fig. 75.2 causing it to appear as if it is much more elevated than the left hemidiaphragm. This is usually due to a congenital weakness of the tendinous part of the hemidiaphragm and is of no clinical significance. Normally, the right hemidiaphragm is about 1-2 cm higher than the left. Case 76. This elderly female smoker presented with loss of weight. Her CXR is shown Fig. 76.1 .
Case 41 Massive Left Pleural Effusion
The CXR shows a dense homogeneous whiteout of almost the entire left hemi-thorax associated with a shift of mediastinum to the right, consistent with a massive left pleural effusion. Collapse and previous pneumonectomy may cause a similar appearance except that the mediastinum is shifted to the ipsilateral side. All patients with unilateral pleural effusion should be considered for thoracocente-sis to determine the cause of the effusion. The commonest cause of a massive pleural effusion is...
Case 62 Lung Cancer With Lymphangitis Carcinomatosis
The CXR shows a left upper lobe mass and mid-zone infiltrates with a normal heart size. In addition, there are Kerley B lines Fig. 62.2 in the periphery of the left mid zone, suggestive of lymphatic distension. These features are consistent with the advanced lung cancer metastasizing to the lymphatics. The prognosis is extremely poor. Case 63. This 24-year-old female was asymptomatic. Six months ago, she presented with pneumonia-like symptoms of cough, fever, and purulent sputum. Describe her...
Case 94 Bilateral First Rib Fractures
The most obvious abnormality is that the first rib margin is discontinuous bilaterally. This is better shown on the apical lordotic view Fig. 94.2 . First rib fractures are usually high-impact injuries as they tend to be protected by the clavicle. They may also be associated with cervical spine and other serious head and neck injuries. The consequence of the fracture is also important as distortion of the anatomy of the blood vessels and nerves may occur. Case 95. This patient presented with...