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I N T E R P R E T I N G C H E ST X- R AY SIllustrated with 100 CasesInterpreting chest X-rays can seem bafing and intimidating for junior doctors. This highlyillustrated guide provides the ideal introduction to chest radiology. It uses 100 clinical casesto illuminate a wide range of common medical conditions, each illustrated with a chest X-rayand a clear description of the signicant diagnostic features and their clinical relevance.Where appropriate, CT scans and bronchoscopic imaging are also included as part of theinvestigation. Pulmonary medicine is largely based on the strong foundation of the plain chest radio-graph. Indeed, chest radiography is the single most common investigation carried out in hos-pital practice. This collection of case studies will help make the learning process easier, moreenjoyable, and less painful. As well as offering enlightening pearls of core knowledge in chestX-ray interpretation, it highlights some of the pitfalls that might wrong-foot the inexperi-enced practitioner.Dr. Philip Eng is Head of the Department of Respiratory and Critical Care Medicine at theSingapore General Hospital, and Clinical Associate Professor of Medicine at the NationalUniversity of Singapore.Dr. Foong-Koon Cheah is Director of Body Imaging and Director of Teaching and Education atthe Department of Radiology at the Singapore General Hospital.

INTERPRETINGC H E ST X- R AY SIllustrated with 100 casesPhilip EngandFoong-Koon CheahSingapore General Hospital

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, So PauloCambridge University PressThe Edinburgh Building, Cambridge , UKPublished in the United States of America by Cambridge University Press, New Yorkwww.cambridge.orgInformation on this title: www.cambridge.org/9780521607322 P. Eng and F.-K. Cheah 2005This publication is in copyright. Subject to statutory exception and to the provision ofrelevant collective licensing agreements, no reproduction of any part may take placewithout the written permission of Cambridge University Press.First published in print format 2005- ---- eBook (NetLibrary)- --- eBook (NetLibrary)- ---- paperback- --- paperbackCambridge University Press has no responsibility for the persistence or accuracy of sfor external or third-party internet websites referred to in this publication, and does notguarantee that any content on such websites is, or will remain, accurate or appropriate.

CO N T E N T SPreface page viiCases 1 to 100 1Index 201

P R E FA C EThis book arose because of the huge amounts of clinical material that pass throughthe Singapore General Hospital, the largest tertiary care hospital in Singapore. Asignicant proportion of our patients come to us for a second opinion from theneighboring countries. Often they come to consult us for an abnormality on achest radiograph. Pulmonary Medicine is largely based on the strong foundation ofthe plain chest radiograph. Indeed, chest radiography is the single most commoninvestigation carried out in hospital practice. This book is targeted towards nal-year medical students and residents in a medical training program. We have givencountless tutorials to generations of medical students, residents, and fellows andwe hope that this collection of pearls can help make the learning process easier,more enjoyable, and less painful. Readers are advised to read this book from cover to cover as the cases are laidout in an increasing order of complexity. The latter cases assume some fundamen-tal knowledge which is laid out in the earlier cases. The authors have intentionallymade the cases as clinically relevant as possible so that interest is sustained andthe book will not be heavy going. P. E N G F. K . C H EA H

1 Interpreting Chest X-Rays CASE 1 Fig. 1.1 Case 1. A 35-year-old male presented with fever, cough, and purulent sputum for one week. This was his CXR (Fig. 1.1). What is the diagnosis?

CASE 1 Interpreting Chest X-Rays 2 Fig. 1.2 Ao SVC LA RA LVCASE 1 PNEUMONIAThe CXR shows a focal shadow in the right lower lobe with air bronchograms sug-gestive of pneumonia. It is clearly in the right lower lobe because the right hemidi-aphragm is eaced. Right middle lobe shadows would eace the right heart border.The presence of air bronchograms indicates pathology in the alveoli, as the con-ducting airways remain patent with air. Water or blood can also occupy the alveolias a result of pulmonary edema or pulmonary hemorrhage respectively. Thereshould be other supporting signs such as cardiomegaly, upper lobe diversion, andKerley B lines with pulmonary edema. The dierential diagnoses of a focal shadowwith air bronchograms include bronchoalveolar cell carcinoma and lymphoma. Itis important to follow-up the CXR to ensure that total resolution of infectionoccurs. This may take up to three months in the elderly but generally someimprovement usually occurs within a week. The borders of the heart on a PA CXRare shown in Fig. 1.2. SVC superior vena cava, RA right atrium, Ao aorticknuckle, LA left atrium, LV left ventricle

3 Interpreting Chest X-Rays CASE 2 Fig. 2.1 Case 2. This 25-year-old had sudden onset of left-sided chest pain. The CXR is shown (Fig. 2.1).

CASE 2 Interpreting Chest X-Rays 4 Fig. 2.2C A S E 2 L E F T P R I M A R Y S P O N TA N E O U S P N E U M OT H O R A XThe CXR shows the visceral pleura (Fig. 2.2) separated from the parietal pleura byair which now occupies the potential space in the pleural cavity. The visceralpleura must not be mistaken for skin-fold shadows which usually occur in supineor obese patient CXR. In addition, the line from skin folds can be seen to cross thechest wall. In the patient above, the lungs appear otherwise healthy and this condi-tion is called primary spontaneous pneumothorax. It occurs classically in youngmales. This is in contradistinction to secondary pneumothorax which occurs indiseased lungs, e.g. chronic obstructive pulmonary diseases (COPD).Pneumothorax in an erect lm is usually seen at the apex. See Case 60.

5 Interpreting Chest X-Rays CASE 3 Fig. 3.1 Case 3. 50-year-old male presented to the Emergency Room with shock and a four-day history of a febrile illness. He required intubation and was started on inotropes. This was his CXR (Fig. 3.1).

CASE 3 Interpreting Chest X-Rays 6 Fig. 3.2CASE 3 RUPTURED LIVER ABSCESSIt is important to look at the blind areas of the CXR in order not to miss impor-tant clues. These areas are under the diaphragm, behind the heart, the hilum, andthe soft tissues. This CXR shows a lucency over the liver density. The lucency doesnot conform to the usual bowel conguration. In this clinical context, an impor-tant dierential diagnosis to be considered is a ruptured liver abscess. This can beconrmed either by bedside ultrasound or CT (Fig. 3.2). Liver abscesses are usuallydue to organisms like Klebsiella or Amoebiasis. All patients with Klebsiella bac-teremia of unknown origin should have imaging studies of the abdomen to ruleout a liver abscess.

7 Interpreting Chest X-Rays CASE 4 Fig. 4.1 Case 4. This elderly male has exertional dyspnea, orthopnea, and parox- ysmal nocturnal dyspnea. His CXR is shown (Fig. 4.1).

CASE 4 Interpreting Chest X-Rays 8 Fig. 4.2C A S E 4 CO N G E ST I V E H E A R T FA I L U R EThe CXR shows classic evidence of left ventricular failure, i.e. cardiomegaly (car-diothoracic ratio 50%), upper lobe pulmonary venous diversion, and Kerley Blines (which indicate distension of lymphatics). In addition, there is evidence ofsternotomy wires, suggesting previous coronary artery bypass surgery (CABG).Following diuresis, the pulmonary inltrates have cleared (Fig. 4.2). Only uid andblood on the chest radiograph can clear rapidly (within days). This patient also hasa right internal jugular central venous line.

9 Interpreting Chest X-Rays CASE 5 Fig. 5.1 Case 5. A 65-year-old male presented with cardiogenic shock. He had an emergency CABG which was associated with a very stormy peri-opera- tive period. This was his CXR (Fig. 5.1) taken upon arrival at the Intensive Care Unit (ICU). What is the most significant abnormality?

CASE 5 Interpreting Chest X-Rays 10 Fig. 5.2 Fig. 5.3C A S E 5 F O R E I G N B O DY R I G H T LO W E R ZO N EThe CXR shows an opaque density in the region of the right lower zone (Fig. 5.2).Each lung eld on an erect CXR is divided into three zones. The upper zone is anarea which lies above a horizontal line drawn from the medial end of the secondrib anteriorly. The middle zone lies below this and is bordered inferiorly by a linedrawn similarly from the fourth rib. The lower zone lies below this. This opaquedensity is similar in conguration to a tooth which was dislodged during emer-gency intubation of this patient. Foreign bodies are not as common in adults com-pared with children. It can occur silently in patients with decreased consciouslevel. The typical site is in the right main stem bronchus, as this has a more verticalcourse than the left. An example is seen in this CT (Fig. 5.3). Bronchoscopicremoval is the usual initial treatment of choice.

11 Interpreting Chest X-Rays CASE 6 Fig. 6.1 Case 6. This patient was asymptomatic. Her CXR is shown (Fig. 6.1). Name the anomaly.

CASE 6 Interpreting Chest X-Rays 12C A S E 6 C H I L A I D I T I S S I G NChilaiditi described this normal variant in 1911 where the transverse colon is inter-posed between the right hemidiaphragm and the liver. Its prevalence is thought tobe 0.025%. Occasional reports describe patients with Chilaiditis syndrome wherepatients complain of intermittent abdominal pain requiring laparotomy to rule outother causes of peritonism, e.g. perforated ulcer, ruptured appendix. The recogni-tion of the haustrations (indicative of large bowel origin) in the bowel shadows iscrucial to the diagnosis of Chilaiditis sign.

13 Interpreting Chest X-Rays CASE 7 Fig. 7.1 Case 7. This patient was asymptomatic. The CXR is shown (Fig. 7.1).

CASE 7 Interpreting Chest X-Rays 14 Fig. 7.2C A S E 7 A Z YG O U S LO B EThere is a curvilinear density adjacent to the right superior mediastinum with anovoid lower density at its lower end (the azygous vein). The azygous lobe is thecommonest CXR normal variant seen in up to 0.4% of individuals. This is anembryologic variation which results in an accessory lobe at the right upper lobe.The ssure (Fig. 7.2) is due to the invagination of the azygous vein and the condi-tion is of no clinical signicance.

15 Interpreting Chest X-Rays CASE 8 Fig. 8.1 Case 8. This was an 80-year-old male with fever, productive cough, hemoptysis, and loss of weight. This was his CXR (Fig. 8.1). What is the diagnosis?

CASE 8 Interpreting Chest X-Rays 16C A S E 8 A C T I V E P U L M O N A R Y T U B E R C U LO S I SThe CXR shows bilateral upper lobe inltrates with cavities, suggestive of activepulmonary tuberculosis. In general, thin-walled cavities (5 mm) tend to be infec-tive and, when thick-walled (10 mm), squamous cell carcinoma of the lungenters into the dierential diagnosis. Tuberculosis tends to aict the upper lobesand apical segment of the lower lobes. However, within the upper lobe, anteriorsegment involvement is rare. Diagnosis is conrmed by obtaining sputum andstaining with uorochrome or Zeil Nielson and culturing with Lowenstein Jansenmedia. Cavitary upper lobe disease has good correlation with a sputum positivesmear and hence is extremely infectious. Other dierential diagnoses of cavitarypulmonary lesions include infections from Staphylococcus, Klebsiella, anaerobes,and non-infectious causes like squamous cell carcinoma of the lung, pulmonaryinfarcts, Wegeners granulomatosis, and rheumatoid nodules.

17 Interpreting Chest X-Rays CASE 9 Fig. 9.1 Case 9. This 80-year-old male used to work in a sand quarry. He was asymptomatic. His CXR is shown (Fig. 9.1). What is the diagnosis?

CASE 9 Interpreting Chest X-Rays 18C A S E 9 S I L I CO S I SThe CXR shows bilateral inltrates and calcied nodules in both upper lobes.Dierential diagnoses of upper lobe inltrates include silicosis, tuberculosis, andankylosing spondylitis. There is also egg-shell calcication of the hilar lymphnodes. The egg-shell calcication plus the upper lobe nodules are typical of silico-sis. Dierential diagnoses of egg-shell calcication include sarcoidosis, Hodgkinslymphoma following radiotherapy, and coal-workers pneumoconiosis.

19 Interpreting Chest X-Rays CASE 10 Fig. 10.1 Case 10. This 80-year-old male presented with right-sided chest pain and breathlessness. He gave a long history of exertional dyspnea. The CXR is shown (Fig. 10.1).

CASE 10 Interpreting Chest X-Rays 20C A S E 1 0 S I L I CO S I S W I T H P R O G R E S S I V E M A S S I V E F I B R O S I S(PMF)This patients CXR shows a right pneumothorax. In addition, there are bilateraldiuse nodules (10 mm but 2 mm) which could be due to metastatic adenocar-cinoma, silicosis, disseminated histoplasmosis, or varicella infection. In silicosis,some nodules may coalesce to form conglomerate masses in the upper lobescalled progressive massive brosis. Patients with silicosis are predisposed to pul-monary tuberculosis and serial CXR comparison is useful.

21 Interpreting Chest X-Rays CASE 11 Fig. 11.1 Case 11. This 40-year-old male of African origin was asymptomatic and had a routine CXR (Fig. 11.1). What is the likely diagnosis?

CASE 11 Interpreting Chest X-Rays 22 Fig. 11.2C A S E 1 1 B I L AT E R A L H I L A R A N D M E D I A ST I N A LA D E N O PAT H Y F R O M S A R CO I D O S I SCXR shows bilateral symmetrically enlarged hilar and mediastinal lymph nodes.CT (Fig. 11.2) conrms this nding, typical of sarcoidosis. The main dierentialdiagnoses would be lymphoma and tuberculosis, but the lymphadenopathy wouldthen be asymmetrical. Bronchoscopy and transbronchial lung biopsy are positivein 60% of cases, showing non-caseating granulomas and culture negative fortuberculosis and fungus. Blind endobronchial biopsies increase the yield byanother 20% but the gold standard is mediastinoscopy. Incidence in people ofAfrican origin is ten times higher than in Caucasians.

23 Interpreting Chest X-Rays CASE 12 Fig. 12.1 Case 12. A 60-year-old male presented at the Emergency Room with severe chest pain of sudden onset. This was his CXR (Fig. 12.1). What is the diagnosis?

CASE 12 Interpreting Chest X-Rays 24 Fig. 12.2CA SE 12 DISSECTING THORACIC ANEURYSMThe CXR shows widening of the superior mediastinum and a well-dened massinferior and contiguous with the arch of the aorta. In this clinical context, dissec-tion of the arch of the aorta has to be excluded. CT Thorax in another patientshows the presence of an aneurysm (Fig. 12.2) at the aortic arch with thrombus.

25 Interpreting Chest X-Rays CASE 13 Fig. 13.1 Case 13. This 80-year-old male smoker is a known case of COPD. He pre- sented with epigastric pain and worsening of shortness of breath. Arterial blood gas showed acute metabolic acidosis. This was his CXR (Fig. 13.1). What is the most obvious abnormality?

CASE 13 Interpreting Chest X-Rays 26C A S E 1 3 P N E U M O P E R I TO N E U M D U E TO P E R F O R AT E D P E P T I CU LC E RThe CXR shows free air under the right hemidiaphragm, in addition to features ofhyperination. The possibilities include perforated peptic ulcer or GI malignancy,recent laparoscopy/laparotomy, and peritoneal dialysis. It is important to do anerect CXR for the free air to rise to the top of the abdomen. For patients with anasogastric tube in place, instillation of 200 ml of free air before the CXR may aidthe diagnosis.

27 Interpreting Chest X-Rays CASE 14 Fig. 14.1 Case 14. This 75-year-old male had a history of myocardial infarction and now presented with recurrent Ventricular Tachycardia. These were his CXR, PA and lateral (Figs. 14.1 and 14.2).

CASE 14 Interpreting Chest X-Rays 28 Fig. 14.2C A S E 1 4 C A LC I F I E D L E F T V E N T R I C U L A R A N E U R Y S MThe PA and lateral CXR conrm an arcuate density in the region of the left ventri-cle. This is typical of calcication of a left ventricular aneurysm, usually secondaryto previous myocardial infarction. Surgical resection of the aneurysm is potentiallycurative.

29 Interpreting Chest X-Rays CASE 15 Fig. 15.1 Case 15. A 60-year-old male presented with exertional dyspnea, orthop- nea, paroxysmal nocturnal dyspnea, and bilateral painless ankle swelling. This was his CXR (Fig. 15.1). What is the abnormality and sub- sequent management?

CASE 15 Interpreting Chest X-Rays 30 Fig. 15.2C A S E 1 5 P S E U D OT U M O R D U E TO LO C U L AT E D R I G H T P L E U R A LEFFUSIONThe CXR shows classic evidence of congestive heart failure with cardiomegaly,upper lobe venous diversion, and bilateral pleural eusions. In addition, there isan ovoid mass in the right middle zone which seems to be related to the transversessure. This is typical of a pseudotumor due to a loculated pleural eusion dis-tending the transverse ssure. Appropriate management would include diureticsand treatment of the cardiac failure. Repeat CXR a week later showed the disap-pearance of the pseudotumor (Fig. 15.2).

31 Interpreting Chest X-Rays CASE 16 Fig. 16.1 Case 16. A 30-year-old male was seen in the Emergency Room for acute onset chest pain. This was his CXR (Fig. 16.1). Name the most obvious abnormality.

CASE 16 Interpreting Chest X-Rays 32 Fig. 16.2C A S E 1 6 M E D I A ST I N A L E M P H Y S E M A ( P N E U M O M E D I A ST I N U M )The CXR shows free air in the mediastinum and subcutaneous tissues of the neck(Fig. 16.2). The mediastinal air could have come from disruption of the integrity ofthe lung, major airways, or the esophagus. A history of trauma (e.g. motor vehicleaccident with blunt injury to the anterior chest wall by the steering wheel) or iatro-genic instrumentation (e.g. recent endoscopy) is important. Descending infectionsby gas-producing organisms from the oral cavity and neck can cause severe medi-astinitis and result in a similar appearance.

33 Interpreting Chest X-Rays CASE 17 Fig. 17.1 Case 17. An 80-year-old male presented with massive hemoptysis and was intubated. This was his CXR (Fig. 17.1). He gave a past history of being treated for tuberculosis many years ago.

CASE 17 Interpreting Chest X-Rays 34C A S E 1 7 MYC E TO M A R I G H T U P P E R LO B EThe 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 maydemonstrate the fungal ball shifting position. In this condition, a preformed cavitybecomes colonized, usually by the fungus Aspergillus fumigatus. Cavitary diseasemay be secondary to brotic lung disease, e.g. previous tuberculosis, sarcoidosis,or ankylosing spondylitis. Massive hemoptysis can result and bronchial angiogramwith embolotherapy (using coils or gel foam) is temporizing. Surgical resection isdenitive, but bronchopleural stula may result. Unfortunately, most patientshave insucient pulmonary reserve to allow surgical resection.

35 Interpreting Chest X-Rays CASE 18 Fig. 18.1 Case 18. This 68-year-old female had recurrent epistaxis. This was her CXR (Fig. 18.1). What is the diagnosis?

CASE 18 Interpreting Chest X-Rays 36 Fig. 18.2 Fig. 18.3C A S E 1 8 H E R E D I TA R Y H E M O R R H A G I C T E L A N G I E C TA S I A O ROSLER WEBER RENDU DISEA SEThe CXR shows a mass in the right lower zone. The mass has a sharp margin andtwo vessels (supplying artery and draining vein) leading to the mass (Fig. 18.2). TheCT (Fig. 18.3) shows marked enhancement of the mass with contrast conrmingthe presence of pulmonary arteriovenous malformation (pAVM). Of patients withpAVM, 60% have Oslers disease, and 10% of patients with Oslers disease havepAVM. This condition is autosomal dominant. Other sites of involvement includeskin, nose (epistaxis), gastrointestinal (GI) system (bleeding GI and anemia).Paradoxical embolism can occur resulting in cerebral vascular accidents or brainabscess. Pulmonary angiogram and embolotherapy are recommended if the pAVMis more than 2 mm.

37 Interpreting Chest X-Rays CASE 19 Fig. 19.1 Case 19. An 80-year-old female, 100-pack-a-year smoker with 5-year history of dyspnea on exertion. Describe her CXR (Fig. 19.1). What is the diagnosis?

CASE 19 Interpreting Chest X-Rays 38C A S E 1 9 C H R O N I C O B ST R U C T I V E P U L M O N A R Y D I S E A S E( CO P D )The CXR of COPD typically demonstrates evidence of air trapping. The signs arehorizontality of the ribs, hyperinated lungs (normally the right sixth rib bisectsthe right hemidiaphragm), hyperlucent lung elds, bilateral symmetrical attenu-ated pulmonary vasculature, long tubular heart, scalloping and attening of thediaphragm. The commonest cause of COPD worldwide is tobacco smoking.However, it is recognized that alpha-1-antitrypsin deciency can also causeemphysema. One should look out for alpha-1-antitrypsin deciency, especially ifthe COPD patient is young (< 45 years old) or demonstrates basal predominanceon CXR.

39 Interpreting Chest X-Rays CASE 20 Fig 20.1 Case 20. This 55-year-old male was admitted in shock. He was recently diagnosed with inoperable lung cancer. Clinical exam also showed dis- tended neck veins and muffled heart sounds. This was his CXR (Fig. 20.1). What is the diagnosis?

CASE 20 Interpreting Chest X-Rays 40C A S E 2 0 C A R D I A C TA M P O N A D E F R O M M A S S I V E P E R I C A R D I A LEFFUSIONBeck described a triad of hypotension, mued heart sounds, and elevated jugularvenous pressure due to cardiac tamponade from pericardial eusion. Immediatepericardiocentesis is life-saving. The common causes of pericardial eusioninclude malignancy, congestive heart failure, tuberculosis, systemic lupus erythe-matosus, Dresslers syndrome, and uremia. This CXR shows a globular enlarge-ment of the heart, typical of a large pericardial eusion. In addition, there is a massin the right lung in keeping with the primary lung cancer.

41 Interpreting Chest X-Rays CASE 21 Fig 21.1 Case 21. This 65-year-old male had a long history of dyspnea on exer- tion, orthopnea, and bilateral ankle edema. This was his CXR (Fig. 21.1). Should a thoracocentesis be done?

CASE 21 Interpreting Chest X-Rays 42 Fig. 21.2C A S E 2 1 S E V E R E C A R D I O M E G A LY D U E TO E N D STA G EVA LV U L A R H E A R T D I S E A S EThe CXR shows very severe cardiomegaly (the normal cardiothoracic ratio isdened as less than 0.5). Both costophrenic angles show lucency due to aeratedlung, making it unlikely that the patient has massive pleural eusions. The carinais also splayed indicating an enlarged left atrium due to severe mitral valve disease.Hence, in this patient, thoracocentesis should not be done. A simple way toconrm the presence of a pleural eusion is to take a lateral decubitus CXR. A free-owing eusion will layer out (Fig. 21.2). However, the absence of layering on alateral decubitus CXR does not preclude the presence of a signicant pleuraleusion as it may be loculated due to an empyema.

43 Interpreting Chest X-Rays CASE 22 Fig. 22.1 Case 22. This 75-year-old female presented with acute respiratory failure. She had been sick for two weeks with fever, cough, and puru- lent sputum. This was her CXR (Fig. 22.1). What is the diagnosis?

CASE 22 Interpreting Chest X-Rays 44CASE 22 SEVERE PNEUMONIASee Case 1. The CXR shows opacities with air bronchograms involving both lungelds. This is typical of severe pneumonia as evidenced by multilobar involvement.Typical organisms include Streptococcus pneumoniae, Legionella, and gram nega-tives like Klebsiella and Pseudomonas aeroginosa. In South-East Asia, another pos-sible etiologic agent is Burholderia pseudomallei (Meliodosis). Treatment willrequire combination parenteral antibiotics, usually beta lactams plus macrolide oruoroquinolone. The prognosis is dependent not just upon the severity of presen-tation but also underlying age and co-morbidities, e.g. cancer, heart, liver, or renaldisease, and stroke. This patients pneumonia was conrmed to be due to severeLegionellosis.

45 Interpreting Chest X-Rays CASE 23 Fig. 23.1 Case 23. A 30-year-old male presented with cough, shortness of breath and loss of weight over four months. This was his CXR (Fig. 23.1). What is the most likely diagnosis? What physical sign would be useful?

CASE 23 Interpreting Chest X-Rays 46CASE 23 PNEUMOCYSTIS CARINII PNEUMONIA (PCP)The CXR shows bilateral inltrates and air bronchograms with a perihilar distribu-tion. The heart size is normal. There are no Kerley B lines or evidence of upper lobevenous diversion. All these are typical features of PCP. PCP is the most commonlife-threatening opportunistic infection in HIV disease. Generally, the mostcommon opportunistic infection in HIV is oral candidiasis. Oral candidiasis shouldbe looked for in any young patient with pneumonia as it may be a sign of T-cellimmune deciency. PCP can be diagnosed by sputum induction or bronchoalveo-lar lavage. Note that 10% of PCP patients could have a normal CXR.

47 Interpreting Chest X-Rays CASE 24 Fig. 24.1 Case 24. This middle-aged female non-smoker was recently diagnosed and treated as for asthma with little response. This was her CXR (Fig. 24.1). What is the diagnosis?

CASE 24 Interpreting Chest X-Rays 48 Fig. 24.2 Fig. 24.3C A S E 2 4 T R A C H E A L T U M O R D U E TO A D E N O I D C Y ST I CCARCINOMAAll patients diagnosed with asthma should have a CXR. In addition to looking forpneumothorax and transient pulmonary inltrates, one should pay attention tothe tracheal air column. Any obstruction to the major airway can produce awheeze. If the obstruction is high up, i.e. extrathoracic, the sound is described asstridor, i.e. during inspiration. This is in contradistinction to rhonchi which is clas-sically expiratory and due to small airway obstruction. The CXR here shows a bulgein the lateral wall of the mid-trachea (Fig. 24.2) due to a tumor. Possibilities includesquamous cell carcinoma, metastases, mucoepidermoid carcinoma, adenoidcystic carcinoma and carcinoid tumor. Flexible bronchoscopy in this patientshowed a mid-tracheal tumor (Fig. 24.3) and biopsy showed adenoid cystic carci-noma (a low-grade malignancy).

49 Interpreting Chest X-Rays CASE 25 Fig. 25.1 Case 25. This was a routine CXR (Fig. 25.1) in an ICU patient who was admitted for aspiration pneumonia. Name the most obvious abnormality.

CASE 25 Interpreting Chest X-Rays 50 Fig. 25.2C A S E 2 5 M A L P O S I T I O N E D N A S O G A ST R I C T U B EThe tip of the nasogastric tube should be seen within the gastric bubble. In thiscase, 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 inltrates, a typical site for aspira-tion pneumonia.

51 Interpreting Chest X-Rays CASE 26 Fig. 26.1 Case 26. This was a routine CXR (Fig. 26.1) taken after placement of a subclavian central venous catheter.

CASE 26 Interpreting Chest X-Rays 52C A S E 2 6 M A L P O S I T I O N E D R I G H T C E N T R A L V E N O U S C AT H E T E RThe most obvious abnormality is that the right subclavian central venous cathetertip has curled upwards into the right internal jugular vein instead of downwardsinto the superior vena cava. The other nding is that of soft tissue swelling in theright neck and superior mediastinal widening. This patient had severe coagulop-athy and repeated attempts at the central venous catheter insertion resulted in aneck hematoma which had also tracked inferiorly causing a mediastinalhematoma. As a result, the patient required intubation to secure the airway.

53 Interpreting Chest X-Rays CASE 27 Fig. 27.1 Case 27. This patient was asymptomatic. Past history was significant for previous thoracotomy. The CXR is shown (Fig. 27.1).

CASE 27 Interpreting Chest X-Rays 54 Fig. 27.2C A S E 2 7 P O ST L E F T P N E U M O N E C TO MYThere is a homogenous whiteout of the left hemithorax. The dierential diagnosesare complete left lung collapse or post left pneumonectomy. The elevation of thegastric bubble and leftward shift of mediastinum here rule out a massive leftpleural eusion. The presence of surgical clips in the left hemithorax in the vicinityof the left main-stem bronchus (Fig. 27.2) makes a left pneumonectomy very likely.

55 Interpreting Chest X-Rays CASE 28 Fig. 28.1 Case 28. This patient presented with recent onset of dyspnea and streaky hemoptysis. The CXR is shown (Fig. 28.1). What is the radiologi- cal diagnosis?

CASE 28 Interpreting Chest X-Rays 56 Fig. 28.2C A S E 2 8 CO L L A P S E / AT E L E C TA S I S O F T H E L E F T L U N GSee Case 27. There is a homogenous whiteout of the left hemithorax. As in theprevious case, there is evidence of volume loss in the left lung with shift of medi-astinum to the left, crowding of the left-sided ribs and elevation of the left hemi-diaphragm. Flexible bronchoscopy demonstrated near-total occlusion of the leftmain-stem bronchus by a tumor (mucoepidermoid carcinoma, Fig. 28.2). Laserresection of the tumor was then performed, resulting in restoration of ventilationto the left lung.

57 Interpreting Chest X-Rays CASE 29 Fig. 29.1 Case 29. This elderly male patient had recent loss of weight and bone pains. What is the most obvious CXR abnormality (Fig. 29.1)? Name the differential diagnoses?

CASE 29 Interpreting Chest X-Rays 58C A S E 2 9 I N C R E A S E D B O N Y D E N S I T I E S D U E TOO ST E O S C L E R OT I C M E TA STA S E SThe bones show patchy increased density due to metastases from carcinoma of theprostate. The dierential diagnoses are Pagets disease and Fluorosis. Cancer ofbreast or lymphoma may also cause the same appearance. The CXR also showsright lower lobe inltrates, suggesting aspiration pneumonia, common in the laststages of patients debilitated with cancer.

59 Interpreting Chest X-Rays CASE 30 Fig. 30.1 Case 30. This elderly male had recent onset of streaky hemoptysis. Name the radiological sign (Fig. 30.1).

CASE 30 Interpreting Chest X-Rays 60 Fig. 30.2C A S E 3 0 G O L D E N S S S I G N O F R I G H T U P P E R LO B E CO L L A P S EThere is a homogeneous density in the right upper zone and elevation of the trans-verse ssure. Instead of the transverse ssure being straight, there is a bulge at themedial end (Fig. 30.2), giving it an inverted S shape. Golden described this sign andthe explanation for it is that the upper lobe collapse is due to a right hilar masswhich accounts for the medial bulge.

61 Interpreting Chest X-Rays CASE 31 Fig. 31.1 Case 31. This diabetic presented with prolonged pyrexia of uncertain origin (PUO). Describe the CXR abnormality (Fig. 31.1).

CASE 31 Interpreting Chest X-Rays 62C A S E 3 1 D I F F U S E M I L I A R Y S H A D O W S D U E TO M I L I A R YT U B E R C U LO S I SCXR shows bilateral diuse miliary shadows (2 mm diameter) due to miliarytuberculosis. The dierential diagnoses include previous varicella infection, dis-seminated histoplasmosis, and silicosis. A travel history to endemic countries or arelevant occupational history is helpful to distinguish the various causes. Anothervery rare cause of such a CXR pattern is pulmonary alveolar microlithiasis.

63 Interpreting Chest X-Rays CASE 32 Fig. 32.1 Case 32. This 25-year-old female had tiredness and shortness of breath for the past year. Describe the CXR (Fig. 32.1).

CASE 32 Interpreting Chest X-Rays 64CA SE 32 PRIMARY PULMONARY HYPERTENSIONThis patient ts the typical clinical and radiological prole of a patient withprimary pulmonary hypertension. The pulmonary arteries are markedly enlargedwith the right atrial chamber also enlarged. The normal right pulmonary descend-ing artery diameter is less than 16 mm in males and 15 mm in females. The lungelds are clear and the lung volumes normal making lung disease causing pul-monary hypertension unlikely. Other causes to be ruled out are congenital heartdisease and chronic pulmonary thromboembolism.

65 Interpreting Chest X-Rays CASE 33 Fig. 33.1 Case 33. This middle-aged male was involved in a motor vehicle acci- dent where he was the driver and his vehicle was hit from behind resulting in intense chest pain. His CXR is shown (Fig. 33.1).

CASE 33 Interpreting Chest X-Rays 66 Fig. 33.2C A S E 3 3 T R A U M AT I C A O R T I C D I S R U P T I O NThis CXR shows evidence of a widened superior mediastinum and loss of the aorticknuckle and obliteration of the aorto-pulmonary window. There is left apicalcapping as a result of mediastinal blood tracking to the extrapleural region of theleft hemithorax. The trachea is deviated to the right and the left main-stembronchus is depressed. The fth and sixth ribs on the left side are fractured.Sometimes there is an associated left hemothorax. All these are typical features oftraumatic aortic disruption, which usually occurs just distal to the ligamentumarteriosum (Fig. 33.2).

67 Interpreting Chest X-Rays CASE 34 Fig. 34.1 Case 34. This middle-aged female had chronic productive cough for many years. What is the diagnosis (Fig. 34.1)?

CASE 34 Interpreting Chest X-Rays 68 Fig. 34.2C A S E 3 4 B R O N C H I E C TA S I S A F F E C T I N G B OT H LO W E RLO B E SThe CXR shows inltrates especially in the right middle lobe and the left lowerlobe. The ring shadows and tramlines indicate the presence of dilated and thick-ened airways. The CXR ndings were noted a few years previously indicating itschronicity. The accepted modality for the diagnosis of bronchiectasis is a high-resolution CT Thorax which demonstrates these dilated airways in the left lowerlobe (Fig. 34.2) using very thin (12 mm) slices. Bronchography is now seldomused.

69 Interpreting Chest X-Rays CASE 35 Fig. 35.1 Case 35. This middle-aged female smoker was asymptomatic. Describe the CXR abnormality (Fig. 35.1).

CASE 35 Interpreting Chest X-Rays 70 Fig. 35.2 Fig. 35.3C A S E 3 5 S O L I TA R Y P U L M O N A R Y N O D U L E ( S P N ) D U E TOPRIMARY LUNG CANCERThe CXR shows a 1.5 cm solitary pulmonary nodule in the left upper lobe (Fig.35.2). An SPN is described as a single nodule (less than 4 cm) surrounded bynormal lung parenchyma. The dierential diagnoses for SPN include pseudonodules (e.g. skin tags, nipple shadows, and bone lesions), primary lung cancer,solitary metastases, granulomas, arteriovenous malformations, pseudo tumors,and hamartomas. In this patient, the CXR a year ago did not demonstrate theshadow. CT (Fig. 35.3) also demonstrates the nodule to be non-calcied and themargins show spiculation making the nodule highly suspicious for malignancy.Thoracotomy and lung biopsy showed primary Stage 1 lung cancer (adenocarci-noma).

71 Interpreting Chest X-Rays CASE 36 Fig. 36.1 Case 36. This middle-aged male had loss of weight and bilateral cervical lymphadenopathy. His CXR is shown (Fig. 36.1).

CASE 36 Interpreting Chest X-Rays 72 Fig. 36.2C A S E 3 6 M E D I A ST I N A L LYM P H A D E N O PAT H Y D U E TOLYM P H O M ASee Case 11. The CXR shows asymmetric distortion of the mediastinal contour bymarkedly enlarged lymph nodes overlying the left hilum. This is described as thehilar overlay sign the normal left pulmonary artery (Fig. 36.2) is seen through themass (lying at the anterior mediastinum). Other dierential diagnoses includechronic lymphocytic leukemia, sarcoidosis, Castlemans disease, and granuloma-tous disease like tuberculosis or histoplasmosis. The histology from medi-astinoscopy in this patient showed Non Hodgkins lymphoma.

73 Interpreting Chest X-Rays CASE 37 Fig. 37.1 Case 37. This elderly male was asymptomatic. What is the abnormality on his CXR (Fig. 37.1)? What is the cause?

CASE 37 Interpreting Chest X-Rays 74 Fig. 37.2C A S E 3 7 B I L AT E R A L C A LC I F I E D P L E U R A L P L A Q U E SD U E TO A S B E STO S E X P O S U R EThe CXR shows bilateral calcied pleural plaques, especially over the diaphrag-matic pleura. The mid-zones show en face calcication (holly leaf sign). This istypical of asbestos exposure. Previously asbestos was commonly used as an insu-lating material. Asbestos exposure can also result in benign pleural eusion, roundatelectasis, pulmonary brosis (asbestosis), or malignant mesothelioma.Dierential diagnosis of pleural calcication includes previous hemothorax,empyema, and tuberculosis. CT also demonstrates the calcied pleural plaques(Fig. 37.2).

75 Interpreting Chest X-Rays CASE 38 Fig. 38.1 Case 38. This elderly male was bed-bound because of a massive stroke. Over the past week, he developed a low-grade fever and became tachypneic and hypotensive, requiring resuscitation and mechanical ventilation. What is the radiological sign (Fig. 38.1)? What is the diagnosis?

CASE 38 Interpreting Chest X-Rays 76 Fig. 38.2C A S E 3 8 W E ST E R M A R KS S I G N O F A C U T E P U L M O N A R YEMBOLISMThe CXR shows an oligemic right upper lobe (Westermarks sign) due to acute pul-monary embolism. Other causes of a hyperlucent lung include a right pneumo-thorax or huge bullae. Other radiological signs of pulmonary embolism arewedge-shaped infarct (Hamptons hump), plate atelectasis, enlarged pulmonaryarteries, or small pleural eusion. The CXR may also be normal. CT conrms theclot in the right main pulmonary artery (Fig. 38.2).

77 Interpreting Chest X-Rays CASE 39 Fig. 39.1 Case 39. This middle-aged male was asymptomatic. What is the CXR abnormality (Fig. 39.1)?

CASE 39 Interpreting Chest X-Rays 78 Fig. 39.2C A S E 3 9 B A M B O O S P I N E A P P E A R A N C E D U E TO A N K Y LO S I N GS P O N DY L I T I SThe most obvious nding is calcication of the interspinous ligaments causing abamboo spine appearance on CXR, typical of ankylosing spondylitis. This disordertypically aects young males with predominant involvement of the axial spine andthe sacroiliac joints (Fig. 39.2). Upper lobe brosis may also result. The lung func-tion abnormality that results is usually restrictive. There is a very strong associa-tion with HLA-B27.

79 Interpreting Chest X-Rays CASE 40 Fig. 40.1 Case 40. This middle-aged female smoker had hemoptysis and loss of weight. What is the CXR abnormality (Fig. 40.1)?

CASE 40 Interpreting Chest X-Rays 80CA SE 40 MA SS IN RIGHT LUNG ARISING FROM TRACHEA ANDRIGHT BRONCHIAL TREEThe CXR shows a mass in the right upper zone with a pleural eusion, suggestiveof advanced lung cancer. The lower end of the tracheal air column also shows nar-rowing, indicating involvement by the cancer. Lung cancer is the commonestcause of malignant pleural eusion and is usually secondary to smoking.Squamous cell and small cell lung cancer tend to involve the central airways, thelatter often associated with mediastinal lymphadenopathy. Adenocarcinoma of thelung tends to present as peripheral nodules.

81 Interpreting Chest X-Rays CASE 41 Fig. 41.1 Case 41. This middle-aged male presented with fever, productive cough, and shortness of breath of two weeks duration. This was his CXR (Fig. 41.1).

CASE 41 Interpreting Chest X-Rays 82 Fig. 41.2CASE 41 MASSIVE LEFT PLEURAL EFFUSIONThe CXR shows a dense homogeneous whiteout of almost the entire left hemi-thorax associated with a shift of mediastinum to the right, consistent with amassive left pleural eusion. Collapse and previous pneumonectomy may cause asimilar appearance except that the mediastinum is shifted to the ipsilateral side.All patients with unilateral pleural eusion should be considered for thoracocente-sis to determine the cause of the eusion. The commonest cause of a massivepleural eusion is involvement from lung cancer. In this patient, thoracocentesisyielded frank pus due to an empyema. CT thorax (Fig. 41.2) shows enhancement ofboth the parietal and visceral pleura, also called the split pleura sign. This resultsfrom intense inammation of the pleura.

83 Interpreting Chest X-Rays CASE 42 Fig. 42.1 Case 42. This elderly male presented with left-sided persistent chest pain and loss of weight for the past few months. He used to work as an electrician on-board a ship for many years. This was his CXR (Fig. 42.1).

CASE 42 Interpreting Chest X-Rays 84 Fig. 42.2C A S E 4 2 M A L I G N A N T M E S OT H E L I O M AThe CXR shows a small left pleural eusion with blunting of the left costophrenicangle. The left hemithorax is smaller than the right. The mediastinum is alsowidened due to tumor creeping along the pleura. All these are features of malig-nant mesothelioma, which is a primary malignancy of the pleura and typicallyspreads along the pleura as demonstrated on CT (Fig. 42.2).

85 Interpreting Chest X-Rays CASE 43 Fig. 43.1 Case 43. This patient was asymptomatic. This was his CXR (Fig. 43.1).

CASE 43 Interpreting Chest X-Rays 86 Fig. 43.2C A S E 4 3 R I G H T- S I D E D A O R T I C A R C HThe aortic knuckle, which is usually on the left, is now on the right (Fig. 43.2). Thisis a congenital abnormality. The commonest type is associated with an aberrantanterior 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 congenitalheart disease.

87 Interpreting Chest X-Rays CASE 44 Fig. 44.1 Case 44. This patient was asymptomatic. The CXR is shown (Fig. 44.1).

CASE 44 Interpreting Chest X-Rays 88 Fig. 44.2 Fig. 44.3C A S E 4 4 A N O M A LO U S P U L M O N A R Y V E N O U S D R A I N A G E S C I M I TA R S I G NThe curvilinear shadow in the right lower zone is called a Scimitar sign. This is dueto aberrant drainage of the right inferior pulmonary vein (Fig. 44.2) into the inferiorvena 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 isusually of no clinical signicance. The CT scan shows the enhancing vein (Fig. 44.3).

89 Interpreting Chest X-Rays CASE 45 Fig. 45.1 Case 45. This middle-aged female complained of hemoptysis and loss of weight of two months duration. This was her CXR (Fig. 45.1).

CASE 45 Interpreting Chest X-Rays 90C A S E 4 5 L E F T U P P E R LO B E CO L L A P S E D U E TO L U N G C A N C E RThe CXR shows evidence of left upper lobe collapse. There is a hazy, veil-like opaci-cation in the left upper lobe, which does not have a sharp inferior margin unlikeright upper lobe collapse (see Case 30). This is because there is usually no lefttransverse ssure and the lobe collapses anteriorly. There is also volume loss in theleft hemithorax as evidenced by an elevated left hemidiaphragm and crowding ofthe left upper ribs. Sometimes the trachea may also be deviated to the same sideand the aortic knuckle may be obscured by the collapse.

91 Interpreting Chest X-Rays CASE 46 Fig. 46.1 Case 46. This was a 48-year-old male with fever of one weeks duration. He was extremely ill and hypotensive requiring inotrope therapy. His CXR is shown (Fig. 46.1).

CASE 46 Interpreting Chest X-Rays 92 Fig. 46.2C A S E 4 6 D I F F U S E N O D U L A R I N F I LT R AT E S S U G G E ST I N GBACTEREMIA AND SEPTIC LUNG ABSCESSESThe CXR shows nodules in both lungs (Fig. 46.2), which seem to be peripheral andof roughly equal size. The dierential diagnosis would be cannon ball metastasesthough these are typically basal and of unequal size. This patient actually hasKlebsiella bacteremia. In parts of South-East Asia, Burkolderia pseudomallei mayresult in the same CXR appearance. The other important etiologic agent isStaphylococcus aureus bacteremia.

93 Interpreting Chest X-Rays CASE 47 Fig. 47.1 Case 47. This patient gave a history of a recent left thoracotomy for massive hemoptysis. The CXR is shown (Fig. 47.1).

CASE 47 Interpreting Chest X-Rays 94C A S E 4 7 P R E V I O U S L E F T U P P E R LO B E C TO MYThe CXR shows the left hemidiaphragm higher than the right, indicating volumeloss of the left lung. Normally the left hemidiaphragm is about 1 cm lower than theright (at the height of the dome). The left main-stem bronchus is also more hori-zontal than usual, indicating volume loss in the left upper lobe. In addition, thereis subcutaneous emphysema on the left chest wall.

95 Interpreting Chest X-Rays CASE 48 Fig. 48.1 Case 48. This patient was asymptomatic. His CXR is shown (Fig. 48.1).

CASE 48 Interpreting Chest X-Rays 96 Fig. 48.2C A S E 4 8 P E R I C A R D I A L C Y STThe CXR shows a homogeneous opacity in the right cardio-phrenic angle. Thisopacity has a rounded border and sharp margins. The right heart border and thediaphragm are obliterated. CT (Fig. 48.2) shows the mass to be cystic with low-density material. All these are features of a pericardial cyst (also called spring watercyst).

97 Interpreting Chest X-Rays CASE 49 Fig. 49.1 Case 49. This patient was asymptomatic. Her CXR is shown (Fig. 49.1).

CASE 49 Interpreting Chest X-Rays 98 Fig. 49.2 Fig. 49.3C A S E 4 9 P E R I C A R D I A L FAT PA DThe CXR shows opacity in the right cardio-phrenic angle (Fig. 49.2). Again, theopacity has obliterated the right heart margin and the diaphragm. CT (Fig. 49.3)shows the density to be fat making this a pericardial fat pad.

99 Interpreting Chest X-Rays CASE 50 Fig. 50.1 Case 50. This patient with a history of carcinoma of the colon presented with chronic cough and loss of weight. The CXR is shown (Fig. 50.1).

CASE 50 Interpreting Chest X-Rays 100 Fig. 50.2C A S E 5 0 M E TA STA S E S TO L U N G SSee Case 46. The CXR shows bilateral peripheral lung nodules of varying sizes andthis is better demonstrated on the CT (Fig. 50.2). This appearance is typical of lungmetastases. The basal predominance is due to the greater blood supply in the lungbases. Lung metastases can arise from cancers of the breast, colon, rectum, andkidney.

101 Interpreting Chest X-Rays CASE 51 Fig. 51.1 Case 51. This female patient was asymptomatic. Her CXR is shown (Fig. 51.1).

CASE 51 Interpreting Chest X-Rays 102 Fig. 51.2 Fig. 51.3C A S E 5 1 P U L M O N A R Y P S E U D O - N O D U L E S D U E TO N I P P L ESHADOWSThere are two nodules (Fig. 51.2), one in each lower zone where the nipples aresupposed to be. These shadows are typically homogeneous in appearance withsharp margins or sharp lateral margins and an absent medial margin. For patientswith asymmetric nipples, the diagnosis can be dicult but a repeat CXR (Fig. 51.3)with nipple markers can help conrm that the opacity is due to a nipple.

103 Interpreting Chest X-Rays CASE 52 Fig. 52.1 Case 52. This young female had been coughing for the past few weeks. She also had right-sided pleuritic chest pain. Describe the most obvious CXR abnormality (Fig. 52.1).

CASE 52 Interpreting Chest X-Rays 104 Fig. 52.2C A S E 5 2 F R A C T U R E D R I B S W I T H C A L L U S F O R M AT I O NThe CXR shows densities along the anterolateral aspect of the right fth, sixth, andseventh ribs (Fig. 52.2). This appearance is consistent with callus formation alongthe ribs which could be due to cough fractures. An alternate way to view the ribfracture more clearly is a right lateral oblique lm.

105 Interpreting Chest X-Rays CASE 53 Fig. 53.1 Case 53. This middle-aged female presented with a one-year history of exertional dyspnea. Examination reveals clubbing, and chest ausculta- tion revealed velcro-like crepitations. Her CXR is shown (Fig. 53.1).

CASE 53 Interpreting Chest X-Rays 106 Fig. 53.2C A S E 5 3 I D I O PAT H I C P U L M O N A R Y F I B R O S I SThe CXR shows small bilateral lung volumes. There are basal inltrates which areperipheral and cystic in appearance, not unlike a honeycomb. These changes arebetter demonstrated on the CT (Fig. 53.2). This is the typical appearance ofIdiopathic Pulmonary Fibrosis (also known as Cryptogenic Fibrosing Alveolitis).The typical prole is a middle-aged female with shortness of breath over months.It can be associated with connective tissue diseases like rheumatoid arthritis andsystemic lupus erythematosis.

107 Interpreting Chest X-Rays CASE 54 Fig. 54.1 Case 54. This middle-aged woman had symptoms of reflux. This was her CXR (Fig. 54.1).

CASE 54 Interpreting Chest X-Rays 108C A S E 5 4 H I AT U S H E R N I AThe CXR shows a lucent shadow with an air uid level in the lower mediastinum.This is typical of a hiatus hernia because of its midline position with the stomachherniating through the esophageal hiatus. Also the stomach bubble is not seen inits usual position. A barium swallow or CT with oral contrast can be done in doubt-ful cases.

109 Interpreting Chest X-Rays CASE 55 Fig. 55.1 Case 55. This patient gave a history of tuberculosis in the 1950s for which surgery was performed. The CXR is shown (Fig. 55.1).

CASE 55 Interpreting Chest X-Rays 110C A S E 5 5 P R E V I O U S R I G H T T H O R A CO P L A ST YPrior to the advent of eective anti-tuberculous drugs, surgery was the only treat-ment available for patients with tuberculosis. The objective was to cause closure ofthe upper lobe cavities and one option was thoracoplasty which involves resectionof the upper ribs, resulting in lung collapse. In this CXR, the right upper chest isdeformed and the pleural space is calcied. Other procedures performed includearticial pneumothorax, phrenic nerve crush, or plombage.

111 Interpreting Chest X-Rays CASE 56 Fig. 56.1 Case 56. This middle-aged male was asymptomatic. His CXR (Fig. 56.1) remained unchanged for many years.

CASE 56 Interpreting Chest X-Rays 112 Fig. 56.2 Fig. 56.3C A S E 5 6 B R O N C H O G E N I C C Y STThe CXR shows a bulge at the right paratracheal stripe (Fig. 56.2). The right para-tracheal stripe on an erect CXR is normally up to 10 mm wide. Other causes of awidened right paratracheal stripe include lymphoma, congestive cardiac failure,vascular abnormalities, and superior mediastinal masses. The CT (Fig. 56.3) showsa cystic (low-density) mass at the right paratracheal area, likely to be due to a con-genital bronchogenic cyst. Bronchogenic cysts can occur in any part of the medi-astinum but typical sites include the carina, paratracheal, retrocardiac areas, andadjacent to the esophagus in contact with the trachea or main bronchi.

113 Interpreting Chest X-Rays CASE 57 Fig. 57.1 Case 57. This patient gave a history of liver cirrhosis and ascites. The CXR is shown (Fig. 57).

CASE 57 Interpreting Chest X-Rays 114CASE 57 RIGHT SUBPULMONIC EFFUSIONThe CXR shows that the right costophrenic angle is blunted suggestive of a smallpleural eusion. In addition, the right hemidiaphragm has its highest point dis-placed laterally. Normally the dome of the hemidiaphragm should have its highestpoint medial to the midpoint between the midline and the chest wall. These areclues to the fact that there is uid trapped in the space between the right hemi-diaphragm and the inferior aspect of the lung.

115 Interpreting Chest X-Rays CASE 58 Fig. 58.1 Case 58. This elderly patient is asymptomatic. He gave a history of a prolonged severe viral illness previously. This is his CXR (Fig. 58.1).

CASE 58 Interpreting Chest X-Rays 116 Fig. 58.2C A S E 5 8 C H R O N I C C A LC I F I C P E R I C A R D I T I SThe CXR shows calcication of the pericardium (Fig. 58.2) indicative of previouschronic pericarditis. Causes include previous viral pericarditis, asbestos exposure,granulomatous disease like tuberculosis or histoplasmosis, mediastinal irradia-tion, or trauma. However, a signicant number of such cases have no apparentcause.

117 Interpreting Chest X-Rays CASE 59 Fig. 59.1 Case 59. This patient was asymptomatic. The CXR is shown (Fig. 59.1).

CASE 59 Interpreting Chest X-Rays 118 Fig. 59.2C A S E 5 9 R I G H T U P P E R LO B E S P N D U E TO A C A LC I F I E DG R A N U LO M AThe CXR shows a dense right upper lobe solitary pulmonary nodule. The nodule isless than 1 cm (see Case 35) diameter and CT conrms it to be dense and homoge-neously calcied (Fig. 59.2), a characteristic of previous granulomatous diseaselike histoplasmosis or tuberculosis.

119 Interpreting Chest X-Rays CASE 60 Fig. 60.1 Case 60. This patient was admitted to the ICU for septic shock requiring mechanical ventilation and inotropic support. This CXR was taken after admission (Fig. 60.1).

CASE 60 Interpreting Chest X-Rays 120 Fig. 60.2C A S E 6 0 R I G H T T E N S I O N P N E U M OT H O R A XSee Case 2. The CXR shows that the endotracheal tube is too far down and the tip isnow sitting at the origin of the right main-stem bronchus. The ideal position is forthe tip of the tube to be at the level of the clavicles. This patient also had a rightcentral venous catheter inserted. The tip of the central venous catheter shouldideally lie at the junction of the superior vena cava and the right atrium. The otherimportant nding is that of a lucent area at the anterior costophrenic recess on theright side with no lung markings. This is the deep sulcus sign and is indicative of aright pneumothorax (Fig. 60.2). In addition, the right hemidiaphragm is depressedand the mediastinum shifted away indicating a tension pneumothorax.

121 Interpreting Chest X-Rays CASE 61 Fig. 61.1 Case 61. This middle-aged male was diagnosed as having asthma but has not improved following inhaled steroids. His CXR is shown (Fig. 61.1).

CASE 61 Interpreting Chest X-Rays 122 Fig. 61.2 Fig. 61.3C A S E 6 1 T R A C H E A L ST E N O S I S D U E TO T R A C H E O PAT H I AO ST E O C H O N D R O P L A ST I C AThe CXR shows narrowing of the tracheal air column (Fig. 61.2) with calcicationof the wall. Tracheal narrowing can be due to malignant causes (lung cancer, lym-phoma, metastases) or benign causes (post tuberculosis, posttraumatic, amyloido-sis, sarcoidosis, Wegeners, Tracheopathia Osteochondroplastica). TracheopathiaOsteochondroplastica (TO) is an extremely rare condition, characterized by thepresence of multiple osseous and/or cartilaginous submucosal nodules (Fig. 61.3)protruding into the lumen of the airway. Bronchoscopy is diagnostic but treatmentis nonspecic and supportive.

123 Interpreting Chest X-Rays CASE 62 Fig. 62.1 Case 62. This middle-aged male gave a history of lung cancer. Recently, he complained of loss of weight and shortness of breath. His CXR is shown (Fig. 62.1).

CASE 62 Interpreting Chest X-Rays 124 Fig. 62.2C A S E 6 2 L U N G C A N C E R W I T H LYM P H A N G I T I SC A R C I N O M ATO S I SThe CXR shows a left upper lobe mass and mid-zone inltrates with a normal heartsize. In addition, there are Kerley B lines (Fig. 62.2) in the periphery of the left midzone, suggestive of lymphatic distension. These features are consistent with theadvanced lung cancer metastasizing to the lymphatics. The prognosis is extremelypoor.

125 Interpreting Chest X-Rays CASE 63 Fig. 63.1 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 CXR (Fig. 63.1).

CASE 63 Interpreting Chest X-Rays 126 Fig. 63.2CASE 63 BRONCHIOLITIS OBLITERANS ORGANIZINGPNEUMONIA (BOOP)The CXR shows a right lower lobe inltrate which demonstrates some air bron-chograms on CT (Fig. 63.2). In addition, there seems to be a beady appearance tothe inltrates. Pneumonic changes on CXR typically resolve within three months.She subsequently underwent a bronchoscopy and transbronchial lung biopsywhich showed BOOP. This is an idiosyncratic reaction sometimes seen in associa-tion with drugs, chemical inhalation, connective tissue disease, and various infec-tions. This is usually very steroid-responsive.

127 Interpreting Chest X-Rays CASE 64 Fig. 64.1 Case 64. This elderly male had hemoptysis and loss of weight over the past three months. His CXR is shown (Fig. 64.1).

CASE 64 Interpreting Chest X-Rays 128 Fig. 64.2CASE 64 MASS IN THE BRONCHUS INTERMEDIUS WITHCO L L A P S E O F T H E M I D D L E A N D LO W E R LO B EThe CXR shows a density in the right middle zone. The density is demarcated supe-riorly by a horizontal line, the transverse ssure, which is pulled down. The medialborder of the mass has merged with the right heart border indicative of rightmiddle lobe disease. The right hemidiaphragm is also obscured, indicating rightlower lobe disease. These features are consistent with a mass arising from thebronchus intermedius with resultant collapse of the right middle and lower lobes(Fig. 64.2).

129 Interpreting Chest X-Rays CASE 65 Fig. 65.1 Case 65. This young female had been breathless over the last two months. Her symptoms are worse on lying down. Her CXR (Fig. 65.1) is shown.

CASE 65 Interpreting Chest X-Rays 130 Fig. 65.2C A S E 6 5 A N T E R I O R M E D I A ST I N A L M A S S D U E TOLYM P H O M AThe PA CXR shows a mass adjacent to the left heart border. There is hyperinationof both lung elds, suggesting obstructive airway disease. The left cardiac marginis obscured, indicating an anterior mediastinal mass as the heart is an anteriormediastinal structure. CT (Fig. 65.2) conrms that there is a mass in the anteriormediastinum and this mass is compressing the lower trachea and main-stembronchi and right pulmonary artery. The dierential diagnoses of masses in theanterior mediastinum include the 5 Ts: thyroid masses, teratoma, thymicmasses, (terrible) lymphoma, and thoracic aneurysm.

131 Interpreting Chest X-Rays CASE 66 Fig. 66.1 Case 66. This 47-year-old female had streaky hemoptysis for two years associated with dyspnea on exertion. What does the CXR show (Fig. 66.1)?

CASE 66 Interpreting Chest X-Rays 132 Fig. 66.2 Fig. 66.3CASE 66 RIGHT LUNG OLIGEMIA CARCINOID TUMOR OFR I G H T M A I N ST E M B R O N C H U SThe CXR shows a hyper-lucent right lung associated with volume loss as indicatedby an elevated right hemidiaphragm. CT conrms the presence of the mass in theright main-stem bronchus and the oligemic right lung (Fig. 66.2). Air trapping maybe demonstrated on an expiratory CXR showing an exaggeration of the oligemiaand the shifting away of the mediastinum. In this patient, bronchoscopy showed aslow-growing carcinoid tumor in the right main-stem bronchus (Fig. 66.3). Thedierential diagnoses of a hyper-lucent lung are bullae, acute pulmonaryembolism, pneumothorax, Macleods syndrome, and a ball-valve-eect type ofbronchial obstruction.

133 Interpreting Chest X-Rays CASE 67 Fig. 67.1 Case 67. This patient presented with stridor due to thyroid goiter and was intubated (Fig. 67.1). Repeat CXR was done six hours later (Fig. 67.2). What is the main radiological abnormality? What is the cause?

CASE 67 Interpreting Chest X-Rays 134 Fig. 67.2 Fig. 67.3C A S E 6 7 F L A S H P U L M O N A R Y E D E M A D U E TO U P P E R A I R WAYO B ST R U C T I O NThe rst CXR shows a normal cardiac shadow associated with bilateral perihilaralveolar inltrates suggestive of acute pulmonary edema. The development of pul-monary edema with a normal heart size is indicative of an acute event. The rapidclearance of the pulmonary inltrates here indicates that the process is rapidlycorrected by positive pressure. In this patient, an important consideration is nega-tive pressure pulmonary edema due to upper airway obstruction from the thyroidgoiter, which is seen on the CT (Fig. 67.3).

135 Interpreting Chest X-Rays CASE 68 Fig. 68.1 Case 68. This elderly female presented with left-sided chest pain of three months duration. Name the CXR abnormalities (Fig. 68.1).

CASE 68 Interpreting Chest X-Rays 136 Fig. 68.2C A S E 6 8 L E F T P L E U R A L E F F U S I O N A N D LY T I C L E S I O N I N T H EL E F T T H I R D R I B S U G G E ST I V E O F M E TA STAT I C D I S E A S EThe CXR shows a moderate-sized left pleural eusion, which is loculated. There isalso globular cardiomegaly, suggesting a pericardial eusion. Pleural tap showedmalignant cells consistent with the diagnosis of adenocarcinoma of the lung. Inaddition, the second, third, and fourth ribs on the left side (Fig. 68.2) demonstratelytic lesions in keeping with bony metastases. Bone scan would be helpful in con-rming the bone metastases. These are all features of advanced lung cancer withmetastatic involvement.

137 Interpreting Chest X-Rays CASE 69 Fig. 69.1 Case 69. This 50-year-old female with a past history of tuberculosis had chronic cough over the past year. Describe her CXR (Fig. 69.1).

CASE 69 Interpreting Chest X-Rays 138 Fig. 69.2C A S E 6 9 L E F T LO W E R LO B E CO L L A P S EThere 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 smallerthan the right. In addition, the left hemidiaphragm is obscured indicating a leftlower lobe collapse. At bronchoscopy, she was found to have a benign stricture ofthe left lower lobe orice (Fig. 69.2) from previous tuberculosis.

139 Interpreting Chest X-Rays CASE 70 Fig. 70.1 Case 70. This 35-year-old female had a long history of chronic produc- tive cough. Her CXR is shown (Fig. 70.1).

CASE 70 Interpreting Chest X-Rays 140 Fig. 70.2C A S E 7 0 D E X T R O C A R D I A D U E TO K A R TA G E N E R S S Y N D R O M EThis patient has obvious dextrocardia (the heart is on the right side) and situsinversus (the stomach bubble is also on the right side instead of the left). There isalso right lower lobe bronchiectasis (Fig. 70.2) as evidenced by bronchial wallthickening, bronchial opacication (bronchocele), and loss of volume.Dextrocardia and situs inversus may be associated with ciliary dysfunction causingsinusitis and bronchiectasis. This is called Kartageners Syndrome.

141 Interpreting Chest X-Rays CASE 71 Fig. 71.1 Case 71. This elderly male alcoholic had a binge and subsequently pre- sented with alcoholic intoxication and vomiting. His CXR is shown (Fig. 71.1). What is the main abnormality?

CASE 71 Interpreting Chest X-Rays 142 Fig. 71.2 Fig. 71.3C A S E 7 1 M E D I A ST I N I T I SThere is a right-sided pleural eusion and, in addition, an air-uid level is notedbehind the right side of the heart (Fig. 71.2). This is typical of a perforated esopha-gus (Boerhaaves Syndrome due to a full thickness laceration leading to media-stinitis from vomiting) resulting in free air in the mediastinum and a pleuraleusion. This patient had food particles at tube thoracostomy. CT scan shows theright hydropneumothorax due to the resultant empyema (Fig. 71.3).

143 Interpreting Chest X-Rays CASE 72 Fig. 72.1 Case 72. This elderly male was totally asymptomatic (Fig. 72.1). What does the CXR show?

CASE 72 Interpreting Chest X-Rays 144 Fig. 72.2