Case 1

These are some sample images meant for illustration of anatomical information visible on a radiograph. These are taken from my earlier presentations elsewhere, more than three decades old. Radiology residents should understand the significance of all these anotated images. These details are seen on radiographs. The first image shows a posterior extent of the lung in the chest cavity. Medial boundary on the right lung is partly represented by azygo-oesophageal line. On the left side is the aortic line. Notice that the lung extends beyond the contour of the diaphragm. A small part of the posterior junction line (meeting of the lungs posteriorly) is seen in the upper thoracic region. In the second image you will see the anterior extent of the lung, lower margin of which is higher, covers a lesser extent of the hemithorax. The anterior junction line is obliquely located in the mid anterior chest. (Meeting of lungs anteriorly). A combination image shows the extent of overlap of the anterior and posterior parts of the lungs. Lastly you should be able to interpret those lines, drawn on the lateral radiograph. How to differentiate right and left oblique fissures? Well, the right oblique fissure has a companion–the horizontal fissure. Whereas the left oblique fissure stands taller, is much higher. Interpretation of the lateral chest is a forgotten art. My personal view is that, present day radiologists are less fortunate regarding the challange of image analysis, but tend to be more factual, focused and detail oriented in the practice. Vintage radiologists had a lot more fun and pleasure in making analytical image based diagnosis.

Case 2 

This example is a test for your ability note subtle observations. Did you see the abnormality? You should at least point out a linear density at left lower zone. When you see a near normal radiograph, look for the review areas. In this case you have a clue. Scrutinize the linear density further. It is part of a thin walled cyst. Rest of the outline of the cyst is very faintly visualized. CT examination demonstrated a large cyst in the middle lobe.

Case 3 

Patient has obvious cardiomegaly with predominant enlargement of right-sided chambers. Also seen is mild mediastinal widening. All these observations could be due to valvular heart disease. Additionally, the patient is presenting with pulmonary opacities, slightly lobar in distribution. Is it part of the cardiac disease? Does this pattern go along with evidence of pulmonary edema? Or is there any other lung disease coexisting with the cardiac condition?

In this case, these findings do not go with the pulmonary venous congestion or pulmonary edema. Ground-glass lobar densities in this patient were due to COVID-19 pneumonia. They do not follow a pattern of gravity.

Case 4

Firstly, you have to decide the precise location of this opacity on the radiograph. The question is 'Is it intrapulmonary or extra pulmonary' ? This question arises when opacities are close to the mediastinum. There are classical signs to separate these two entities, namely the interface between the lesion and the rest of the pleural space whether it is acute or obtuse;(extra-pleural sign), Intrinsic features of parenchymal disease like air bronchogram, cavitation etc. 

What do you think the likely location is in this case? Students when describing this lesion should precisely describe the lesion, define the plane of the lesion and explore the presense of any silhouette sign or specific lesion characters.

Overall, the features in this case are in favor of an intrapulmonary mass lying adjacent to the mediastinum. Further evaluation revealed it to be a bronchogenic carcinoma. Brain evaluation demonstrated metastatic disease. (Case is also illustrated elsewhere)

Case 5

Unilateral opaque hemithorax is a classical context for discussion. Two major categories exist - one in which there is volume loss; other in which there is mass effect from opaque hemithorax. Additional signs of these two aspects are to be analysed. What is your impression in this case? Loss of volume vs. mass? Now look for airways, cardio-mediastinal structures, diaphragm and chest wall. It is obvious that there is loss of volume. Now the choice is between pneumonectomy vs. total lung collapse. This patient had pneumonectomy.

Case 6

This is a case one can use to familiarize themselves with evolving cardiac treatment techniques and implanted structures. Description, as far as a student is concerned, should be typical for a post-operative state. The question is: where exactly this radio-opaque ring located? This appearance is due to an implanted pulmonary valve. Note that it is not located in a typical mitral or aortic location.

Case 7 

This can be a typical examination case. It is not very difficult to identify the abnormality here. Most of the routine observations  are negative, except that the heart looks radiolucent. Margins of this radiolucency are fairly sharp and oblong supero-inferiorly in distribution. Perhaps you have guessed that this could be part of the oesophagus or GIT seen through the cardiac shadow. Another indirect sign is the absence of a gastric bubble. This patient had a gastric pull-up as part of a surgery for tracheoesophageal fistula in early childhood.

Case 8 

Systematic approach to chest interpretation is extremely important. Many are familiar with options;  an approach either from inside out or from outside in – encompassing all the important 5 structures under evaluation. This is an example that tests such ability. I am sure some observation can be made on the parenchymal opacities at left lower zone with a blunt CP angle. On close scrutiny you will notice a malunited fracture of the middle third of right clavicle and fracture of the scapula. In fact, the patient also had a pulmonary contusion and hemothorax on the left side, which had lead to this complication of pleural thickening.

Case 9 

Many observations are present in this radiograph, most of them obvious. Note is made of the cystic bronchiectatic changes in the left lower lobe. Additionally, you can note an exaggerated parenchymal pattern in the lower zones with some peribronchial cuffing. Did you notice the pulmonary artery branches, with obvious dilatation and pruning of the right pulmonary artery? Also, there is mild enlargement of the cardiac shadow. Interpretation of this radiograph should be complete, describing the chronic pulmonary condition, bronchiectasis, and its secondary effect, the developing pulmonary arterial hypertension. Also known as, Cor-Pulmonale. Development of pulmonary arterial hypertension and chronic lung disease in an unfavorable sign.

Case 10 

This is a test case for all hospital based radiologists. This case is not particularly difficult to diagnose. An obvious observation is decreased aeration of right lung and hyperinflation of the left. Is it an intrinsic primary condition or is it iatrogenic? If you observe closely, tip of the endotracheal tube is in the right bronchus, which partly explains the situation. There are various possibilities when the endotracheal tube is located in one of the bronchus. Findings will depend on extent of occusion and the ventilator setting: on high setting there may be selective hyperinflation of the intubated lung. On low settings there may be lung collapse. Effect on the contralateral lung also can vary from complete occlusion to hyperinflation. What was the surgery done for this patient? That information is available in the form of a stent located at the level of coarctation for which patient was operated. The procedure can also be done these days with an endovascular approach. Note the faint opacification of kidneys due to previously injected contrast.

Case 11 

73-year-old male with exertional dyspnoea. Patient had a previous myocardial infarction.

This is a very old radiograph of an elderly male with dyspnoea. Did you make any significant observation in the radiograph provided? It is difficult to make clear impression on the frontal view. Aortic arch is somewhat denser due to ectasia. Finding is confirmed on the lateral view in the form of increased density of structures overlying the upper thoracic spine. More interesting observation is noted in the lateral view which also shows a convex bulge in the posterior cardiac contour, a location represented by the left ventricle. Patient had a left ventricular aneurysm secondary to the earlier myocardial infarction.

Case 12

Chest radiograph of a 66-year-old lady with fever and dyspnoea.

This illustration is presented to show subtle findings of a currently relevant entity, COVID-19 pneumonia. Findings are subtle. What is visible is a ground-glass density along the chest wall on the right side and subtle findings at the subpleural region of left lower zone. COVID-19 pneumonia in the early stage presents with this manifestation. Findings should be appreciated separately from the overlying soft tissues. There is often, hypoaeration of lung bases.

Case 13

30-year-old female with intermittent chest pain after food. Chest frontal view is provided.

Imaging diagnosis is obvious in this case. There is elevated, relatively thin left diaphragmatic dome, with the underlying air distended stomach. Often such findings are seen either with the eventration of the diaphragm or a sequel of earlier diaphragmatic paralysis. The most important finding in this patient is the position of the heart which is showing contralateral displacement. This finding is relevant in patient management and assessing need for any possible surgical requirement. Fluoroscopy is helpful in appreciating the complete extent of displacement.

Case 14 

36-year-old male patient with breathing difficulty on ventilator and a positive PCR for COVID-19.

These two radiographs, taken one day apart, illustrate the rapid dynamic changes in the critical observations . Left radiograph is an earlier one, showing extensive pneumomediastinum and left chest wall emphysema. Lung is moderately inflated, does show extensive ground-glass opacification. Right radiograph shows significant decrease in the interstitial emphysema of the chest wall, marginal reduction in pneumomediastinum. However, lung aeration is very poor leading to loss of volume in both lungs. This is one of the management challenges, to keep the lungs well aerated while avoiding air leak complications. Similar analogy exists in the management of surfactant deficiency disease in the newborn (illustrated elsewhere).

Case 15

13-year-old male with the wheezing and cough.

This radiograph is tabled for detailed radiographic analysis. You might have noticed that there is an abnormality in the right para-cardiac region. Part of the right cardiac border is obliterated. This introduces us to the concept of silhouette sign, described by the famous American radiologist Benjamin Felson. The concept is that anatomical contiguity leads to possibility of continuous density on radiograph when structures have near-similar-physical parameters. In this context, a lesion (consolidation/collapse) in the middle lobe, which is in anatomical contiguity with the right cardiac border, will obliterate the cardiac border on radiography. Wider application of the same can be utilised by understanding the anatomical contiguity of various structures in the chest. Middle lobe is in contact with right cardiac border, lingula is in contact with the left cardiac border. Lower lobes are in continuity with the diaphragm etc. When scrutinizing radiographs, it is important to note all the observations available on the radiograph. Did you notice the hypoplastic fifth rib on the right side? This patient had bronchial asthma with middle lobe sub-segmental collapse.

Case 16

Plain and contrast CT images of the chest are provided with reconstructions in coronal and sagittal planes. Do you have an observation and diagnosis in this case? 

This is a case with many subtle observations. There is a peripheral lung opacity with infiltrating irregular margins in the apical segment of the right lower lobe. Lesion is in contact with the pleural interface, associated with minimal pleural fluid/thickening. If you carefully observe, the right hemithorax is smaller than the left. Additionally there is gross thickening of interstitial shadows of the right lung, thickening of the adjacent fissures. Images in the bone window demonstrate sclerotic foci in multiple vertebral bodies. Indeed, this patient had bronchogenic carcinoma leading to lymphangitis carcinomatosis of the right lung and metastatic disease involving the spine.

Case 17

Middle aged male, presented with acute chest pain and difficulty in breathing.

Multiple contrast-enhanced CT images are provided in axial, coronal and sagittal planes. This exam needs some time to review all the images. Information is obvious on close scrutiny. There are findings in the left lower chest in the form of minimal fluid and air containing structures in left lower chest. It is obvious on scrutiny of all the images that the left dome of the diaphragm is incompletely seen and abdominal contents are seen in the lower thorax. This is a case of acute diaphragmatic rupture. Often this form of injury is seen in patients with blunt trauma. Demonstration of minor diaphragmatic injury needs good imaging protocol.

Case18

4-month-old child with a respiratory infection.

Examples of many chest exams are illustrated in this work so as to provide wider exposure to the viewers. What is your observation/diagnosis? Right upper lobe consolidation/minimal loss of volume are obvious. Remaining lungs are hyperinflated. There is sub-segmental atelectasis in the medial parts of lower zones. Any other finding you notice? You will be given some credit if you noted a loop of large bowel extending up, overlying the cardiac shadow. This is a Morgagni hernia, in addition to the chest lesions. This case also illustrates the inverted V sign of transverse colon seen in patients with Morgagni hernia.

Case 19

6 month child evaluated for chest infection, wheezing.

Interpretation of the chest is always challenging. This radiograph shows an area of radiolucency with slight mass-effect in the left lower zone. In a slightly older child an aspirated foreign body is a possibility. In this case it was lobar emphysema (lobar hyperinflation). Note that both hilar shadows are somewhat ill-defined, probably due to expiratory phase. CT evaluation and follow-up radiograph are  necessary to see the extent and progression of the disease.

Case 20

Chest radiograph of a four-month child with fever and respiratory distress.

This chest radiograph demonstrates the classic appearance of airspace opacities with a small cavitations. A classical pneumococcal consolidation is generally homogeneous, and may show a bronchogram – radiological evidence of consolidation. Air bronchograms are variable in children. However presense of any cavity is a bad sign, indication of either pneumatocele formation or areas of breakdown. This patient had a severe staph pneumonia with multiple abscesses. Some pathological correlation is provided in the form of a web source.

Case 21

6 month child with the chest infection.

Frontal and lateral chest radiographs are provided. Two frontal views are done within an interval of a few days.

Do you have any diagnosis? In this young age group, hyperinflated lungs could be part of lobar emphysema. In this case it was a right lower lobar emphysema causing compression of the upper lobe and contralateral herniation across the midline. You also note the radiolucency of the posterior lung fields in the lateral view. Progressive congenital lobar emphysema (presently called congenital lobar hyperinflation) can be a surgical emergency. Common sites of involvement is the left upper lobe, right middle lobe and right upper lobe. Lower lobe is not a common site of the lesion. There may be associated bronchomalacia with focal obstruction; occasionally compression of the bronchus by an aberrant left pulmonary artery when the lesion is on the left side. Post surgical outcomes are generally good.

Case 22

Chest radiograph as a followup of a surgical procedure.

Your observation should be that there is a mass-effect in the left hemithorax either due to a pneumothorax or hyperinflated lung. Which one is more likely? To decide this, the lung border should be identified. In this case we do not see the lung interface. This is a trick case for a radiologist, but a simple case for a paediatric surgeon who is well informed about clinical status. Follow-up radiograph is presented. There is a long air-fluid level in the left pleural space. This is a large hydropneumothorax in the left pleural cavity after repair of a congenital diaphragmatic hernia. This is a usual postoperative process that takes place after reduction of a large hernia. Cavity will resolve and organize with time. You do not see the lung in this case because it is hypoplastic, too early to predict the future outcome of lung expansion.

Case 23

Newborn infant with respiratory distress.

This is another Aunt Minnie chest radiograph of the congenital diaphragmatic hernia. Bowel loops are filling the left hemithorax, causing contralateral displacement of the cardiac shadow. Position of endotracheal tube and nasogastric tube will also show the displacement. Important thing in this instance is to assess the lungs, whether they are normally developed or not. Hypoplastic lung is one of the prognostic indicator for the surgical outcome of diaphragmatic hernia repair. Mediastinal vascular compression also contributes to the overall clinical picture. Note that there are still bowel loops in the abdomen, probably loops of large bowel. Immediate and late postoperative chest films are provided. Note that initially the chest cavity is replaced by large pleural space. Subsequently the left lung showed some expansion. Depending on the maturity of the left lung subsequently the chest cavity will be occupied by the left lung

Case 24

This is a 15-year-old adolescent with recurrent chest infection following viral pneumonia. Patient had progressive dyspnoea.

Chest X-ray and the representative CT images are provided. Chest X-ray shows predominantly lower and mid zonal, somewhat linear, band-like opacities, representing areas of sub segmental atelectasis. Upper zones are relatively spared. Findings are collaborated on the CT examination which shows multifocal atelectasis with areas of hyperinflation. These areas represent areas of organizing pneumonia (BOOP). This entity is relatively more common in slightly younger children. These areas of organizing pneumonia may undergo fibrosis.

Case 25

35 year-old male known to have a viral exanthem.

Not all are fortunate to see such cases in the practice. I encountered this case in a patient known to have chickenpox. Lung changes are military-nodular opacities with ill-defined outline–classic appearance of a chickenpox pneumonia. Some opacities appear to cavitate. Patient recovered completely without antibiotics. Some of these cases may show fine foci of calcification on healing. 

Case 26

This set of images demonstrates chest radiograph, chest sonography images and CT examination of the thorax. Diagnosis of upper pleural effusion is not very difficult. Essentially a pleural base shadow will be observed, continuous with the chest wall and diaphragm. Dependent positioning is often demonstrated in the radiographs. Classic C-shaped upper margin may not be clearly evidenced in the child. Nature of pleural fluid is very important in the context of sepsis. Plain radiography may show some clue in the form of a loculation. Ultrasonography has a greater value in showing the intrinsic nature, septations etc. CT with contrast precisely locates the fluid, enhancing walls and loculations. Sonography and CT can be used for guiding drainage procedures. There is a supportive illustration showing the pathology of inflammatory pleural disease.

Case 27

This patient is a 63-year-old male investigated for a headache. He had angiographic evaluation of the intracranial vessels.  Axial and reconstructed images of the upper mediastinum are provided. Indeed this is one of the very rare cases, not often encountered in routine practice. Those who were very familiar with complex intervention of the thorax may appreciate the observation straight away. What we are seeing here is a small aneurysm from the right bronchial artery, lying posterior to the carina. Provided 3D rendering makes the lesion too obvious. Bronchial arterial aneurysms (also referred to as pseudo-aneurysms) constitute less than 1% in those undergoing bronchial angiography. Patients may be either asymptomatic or may lead to compression of adjacent organs if large. They are known to be more frequent in patients with silicosis, bronchiectasis, trauma and occasionally in association with syndrome (Rendu Osler Weber). Transcatheter embolisation is a treatment of choice.

(Case prepared in collaboration with Dr Vinay Belval.)

Case 28

60-year-old male with exertional dyspnoea and chest pain. Investigated with plain radiography. Frontal and lateral views are provided. 

It is always interesting to initially evaluate the cases on plain radiographs. What is your impression looking at the chest radiographs? There is gross cardiomegaly with predominant bulging of the cardiac shadow to the left side. In the lateral view lesion is globular filling of the retrosternal space as well as extending posteriorly. There is no calcification or any specific differentiating features. There are no specific features of chamber enlargement. Gross cardiac dilatation can be seen in patients with dilated cardiomyopathy, pericardial effusion, multivalvular disease and Ebstein’s disease. Sometimes mediastinal masses in relation to the heart can cause of apparent cardiac enlargement. Multimodality imaging is needed for further differentiation. This patient had a contrast CT.

Case 28

Axial CT images without and with contrast are provided. You will notice a soft tissue density behind the cardiac shadow (outlined by a partly visualised fat planes) in the non-enhanced scans. Lesion is posterior to the left ventricle and shows heterogeneity. Clear differentiation of lesion from the cardiac border is almost impossible. Additionally, there is a right-sided pleural effusion. Contrast-enhanced images show the extent of lesion as well as its nature of vascular pattern. Notice that the enhancement pattern is somewhat linear and circular (“whorl like”). Lesion is extending from the level of the aortic arch to the level of the diaphragm. Interface with the myocardium and great vessels is ill-defined in many areas, indicating possible invasion. No suggestion of pericardial fluid. There is no lymphadenopathy. Abdominal structures appear normal. In this context the possibility of a mesenchymal tumour is very likely. It can be of neurogenic origin, mesenchymal origin or a sarcoma. Whorl-like pattern is seen in neurogenic tumours and sarcoma of smooth muscle origin. Lymphoma is a differential diagnosis, and often does not have this specific pattern of enhancement.

Case 29

This is a newborn baby with respiratory distress. 3 X-rays are provided, one taken 2 hours afterbirth, subsequent at 6 hours and 12 hours. 

Not everyone is familiar with neonatal radiography. You may be wondering why such frequent examinations are donefor a such young patient. This was a full term baby. What is your impression of the initial radiograph? Is it compatible with the respiratory distress syndrome/surfactant deficiency syndrome? 

This radiograph has certain interesting observations. If you notice cardiomediastinal structures are somewhat displaced to the right side. Positioning of the neonate is reasonably satisfactory. There is ground glass opacification of the medial part of the left hemithorax. Right lung is not fully aerated. This observation should lead you to question is there a mass-effect in the left hemithorax? If so, what is the likely cause? What happens in the subsequent radiographs? You will notice the right lung is not showing much changes, whereas the left lung which was opaque earlier now is hyperinflated. The mass-effect is progressive with time. What are we dealing with? A seasoned paediatric radiologist will suggest a possibility of either lobar emphysema/hyperinflation or a variant manifestation of adenomatoid malformation.

CT examination was followed up. The observations are much more clearer. There is hyperinflation of the left lung almost uniformly enlarging the left lung. Atelectatic changes are present in the right lung and the remaining part of the left lung. There is no mass lesion or cystic lung lesion. There is cardiomediastinal contralateral displacement. Findings are in favour of lobar emphysema arising from the left upper lobe. Some of the lobar emphysema contain fluid when first seen in the neonate. This is just part of the fetal appearance wherein lung has persistent fluid content, as an abnormal lung (like lobar hyperinflation) takes longer time to clear up.

Case 30

3-week-old child with a chest deformity, investigated with CT.

What are your observations on the CT scan? Is there a mass lesion in the chest? ? What is the cause of a large left chest hemi-thorax?  This CT shows an interesting observation; we are dealing with rib abnormality involving left first and second ribs. They are malformed, enlarged, stumpy and have a pseudoarticulation. Some non specific soft tissue swelling is also present. The process appears benign-either due to dysplastic rib due to a development anomaly  or benign process like fibrous dysplasia or a cartilaginous mass.

Case 31

This patient presents as an example of spontaneous air leak from the airways - during a bout of coughing. Images show pneumo-mediastinum, interstitial emphysema of the neck region, and retroperitoneal air. It is important to observe subtle air in the mediastinum at an early stage. The path of extension of air is closely related to communicating  tissue planes. Cases such as these give a student of Radiology a chance to revisit anatomy.

Case 34

This child had recurrent chest infections since childhood and growth retardation. Series of chest radiographs and CT examination of the chest at a later stage are presented.

With this case I would like to introduce an important element to radiological interpretation. What I want to emphasize is that review of older radiographs is an extremely important part of image reading ( often neglected due to circumstances). Patients do not bring the old examination because they think it is going to bias the interpretation. Sometimes they want to test the skills of the radiologist!!!

After going through the series of radiographs, what is your impression?  What possibilities and /or suggestions would you recommend in this setting?

Recurrent chest infections can be due to few clinical entities. Immune deficiency, genetic or acquired can predispose to recurrent infection. Common variable immunodeficiency is one common entity in the child which can lead to such presentations. Additionally there are groups of diseases wherein mucosal clearance is defective or inadequate. Entities in this category are dyskinetic/immotile cilia syndrome and Kartagener syndrome. The other category includes conditions like cystic fibrosis. Apart from all these conditions generalized debilitation due to chronic disease like malnutrition, hepatic failure, hematological disorders, rickets, celiac disease can lead to such presentation.

Coming to the radiological interpretation, you will notice a near normal radiograph at the age of 6 months. Subsequently you have presentations like consolidation involving the right upper lobe, left lower lobe and left upper lobe etc. You will also note that there is hyperinflation of the rest of the lungs. 

1. What is your interpretation of chest radiographs at the age of 1 year?  With the previous radiographs at hand, diagnosis of complete left lung collapse with ipsilateral cardiomediastinal displacement is not very difficult.  Right lung is grossly hyperinflated.

2. How would you evaluate the radiograph at the age of 1 year and 3 months?  The quality of the radiograph is not very great, nor is the patient's clinical status! I assume you  may have noticed the right pneumothorax, which had brought the patient to the hospital. There are some more follow-up radiographs after chest tube drainage.

Routine evaluation by CT scan in the early stage of the disease in these groups of patients, is not very helpful. Clinical and laboratory screening is more useful at that stage. Later stages when lung disease leads to collapse/cavitations or other complications will need additional cross-sectional imaging. CT examination with contrast confirms complete collapse of left lung with loss of volume (fibrosis) .There is secondary cardiac mal-position. Did you notice a dilated pulmonary artery? What is the significance of this finding? With all this complication, the patient is developing pulmonary arterial hypertension, which will adversely affect the patient's prognosis in the long-term.

A 14-year-old child was involved in a RTA. Patient had breathing difficulty and haemoptysis. You have been provided with the CT images with contrast.

If you want to take due credit or want to feel good about yoursef, this is a case for analysis. I always ask the question' What about your impression' of the case. This is a time to make a mark. 

The right hemithorax is opaque, as the lung has completely collapsed. And you will also notice that there are hypodense non-enhancing areas in the posterior aspect of the collapsed lung, which can present a haematoma/laceration of the lung. And there is an ipsilateral cardiomediastinal shift. Do you think it is a complete diagnosis  or anything else to add? 

I hope you have looked at the coronal reconstruction and adjacent axial contrast-enhanced image at the level of the distal trachea!  You note that there is some irregularity in the right wall of the trachea at carina and there is sudden cut-off of the right bronchus soon after its origin. This finding should lead us to suspect a bronchial injury– lacerated/fracture bronchus. Often this is a very serious condition which should be attended to immediately. Fallen lung sign is an observation in these cases, wherein lung lies low down in the thorax adjacent to the dome, as a pedicle is no longer supporting the lung. There may be variable presentation with additional pneumothorax/haemothorax.

14-year-old male presented with exertional dyspnoea and heaviness in the chest.

Contrast-enhanced CT images and subsequent reconstructions are provided.

In this instance we are noticing a very large, multiloculated cystic lesion in the right lower hemithorax. Lesion is completely occupying the lower 4/5th of the lung with a clear upper and anterior margin. Also lesion is located posteriorly, abutting the chest wall. In the lower section lesion is located more along the chest wall. Partially aerated and partially compressed lungs are visualised anteromedially. There is contralateral cardiomediastinal displacement. Though the lesion is predominantly cystic appearing there are solid septations which appear to enhance uniformly. Left lung is normal. Now we have the question to determine whether the mass is pulmonary or extrapulmonary. Sometimes a simple logic and well-known dictoms does not work while assessing huge lesions in the chest. Generally extrapulmonary lesions are peripherally located, have obtuse angles at the margins, outline is often incomplete (incomplete margin sign), and do not show imaging signatures of Lung tissues. Additionally there may be bony changes. Though this lesion has an acute angle with the chest wall, the bulk of the lesion appears to be in the extrapleural space. Most likely we are dealing with a predominantly cystic mass in the pleural space. There is no obvious bone destruction. However small focus of reactive bone changes is noted in the fifth posterior rib. Extensive bone changes are expected to be seen in lesions like ewing's sarcoma or Askin tumour. This leaves a possibility like a pleural mass (mesothelioma/sarcoma) and other rare entities like a hydatid cyst or multicystic lymphangioma of the pleura.

Case 38

This is a 4-month-old child with cough and breathing difficulty.

Contrast-enhanced axial images of the chest are provided.  I would appreciate full attention to details in the evaluation for this case. Seasoned radiology student should suggest a possible diagnosis.  First step is to document observations. I hope that you have seen an abnormality in the left paraspinal region in the form of right lower thoracic paraspinal, lobulated predominantly hypodense/mixed density lesion with foci of calcification. Peripheral part of the lesion appears cystic. What do you think is a possibility?  Is it a tumour ? - a neuroblastoma. Can it be tuberculosis lesion with an adjacent pleural collection?  Is there any clue to differentiate the entities? 

 I would like you to notice that there is a right paratracheal lymph node. Secondly I hope that you will be able to appreciate the subtle bone destruction involving the adjacent rib.  Indeed this was a case of the tubercular osteomyelitis of the eighth rib with adjacent cold abscess in the paraspinal region.

Case 39

This is a young patient presenting with the dyspnoea and chest pain. You have been provided with contrast-enhanced CT images of the chest with the coronal and sagittal reconstructions.

This is one more exercise of evaluating a mediastinal mass. Presence of the mass is obvious; it is on the left side of the mediastinum. It is elevating the subclavian vessels, almost incorporating them at the periphery of the mass. Medially mass  is insinuating between the great vessels and abutting the aortic arch and adjacent heart. Though lesion looks mostly cystic, more posterior elements are solid and show an enhancement. There is no pleural fluid and the rest of the lungs is clear. In the abdominal examination there is a horseshoe kidney, as an incidental observation. Anything else in the abdomen? 

Liver appears normal whereas the spleen shows a focal, non-enhancing lesion near the splenic hilum. Mediastinal lesion in the child goes with the acronym terrible T’s. Thymoma, Teratoma, Terrible lymphoma and Thyroid masses. This lesion perhaps comes in the category of a Teratoma or teratocarcinoma. Isolated splenic metastasis is very uncommon. Evaluation of laboratory parameters sometimes helps in confirming the presence of hormone producing components of the teratoma. This patient was diagnosed to have malignant teratoma by surgery.

Case 40 

Chest radiograph of a child with a respiratory infection is provided. X-rays are done at an interval of 7 days.

Initially you will notice an area of irregular consolidation at the right upper zone and the both lower zones. Note that there is extensive left retrocardiac disease. In the subsequent followup you have an unusual appearance in the upper zone lesion. There is a cavity with a content evolving in a short span of time. In chronic situations this appearance would be typical for a fungus ball–aspergilloma. But in this child it was due to necrotic pneumonia, necrotic content is lying within the cavity. Patient responded well to antibiotics and showed complete resolution of the lesion.

Case 41

 This 9-year-old female previously had surgery for a right chest lesion. Followup MR examinations are provided. 

MR examination of the chest has some important observations. Any idea as to the nature of surgery done and can you guess likely lesion for which the surgery was done?

There is a minimal residual lesion in the right paraspinal-intervertebral foraminal area (T4/5 level), showing enhancement in the contrast studies. Though the lesion is located in the intervertebral foramen, it does not show intra-spinal extension. There are subtle erosions in the adjacent ribs. This patient had a neuroblastoma of the thoracic sympathetic chain, surgically removed. Due to technical difficulties there was a suspicion of residual lesion. MR examination is superior to evaluate possible intraspinal extension.

Case 42

Testing case for residents. Subtle radiolucency of lungs, sharp cardiac margins in a patient with tachypnoea, should make you suspect pneumothorax. In neonates with supine positioning, location of pneumothorax is anterior. Thymic sail sign is helpful for the diagnosis if present. Lateral view , preferably transliteral views are helpful for confirming the diagnosis. You can appreciate the air anteriorly in the lateral view.. This patient had right anterior pneumothorax.

Case 43

14-year-old patient with recurrent chest infection . Serial chest radiographs are provided done over a period of 3 years.

In all the chest radiograph a common finding is presence of a bilateral perihilar peri bronchial interstitial shadowing of varying extent with associated peripheral lung changes either in the form of atelectasis or consolidation. In addition to this lungs are hyperinflated. If you make a close observation, you will appreciate that there is a progressive dilatation of the main pulmonary artery segment over time. In an adult this appearance is compatible with chronic bronchitis with emphysema. In a child this appearance is often seen in patients with cystic fibrosis. Lesions tend to be progressive lead to complications like extensice consolidation,cavitation, fatal haemorrhage, necrotising lung lesions and pulmonary hypertension. Predominant distribution of the lung lesion is in the upper zones and peribronchial area. There are alveo-nodular ill-defined lesions, often due to secondary infection due to pseudomonas.

Case 44

CT images of the lower chest are provided in a 3-month-old patient. Lesions are bilateral, basal mostly involving the lower lobes in the form of airspace lesions. There is some degree of volume condensation or loss of volume. Some cavitating lesions are also noted in the right upper zone. This patient was known to have Down syndrome and was mostly bedridden. Combination of dependent stasis and poor general condition predispose to dependent hypostatic pneumonia-atelectasis. This leads to almost fibrotic lungs and progress to end-stage disease. Similar appearances also can be seen in patients who are debilitated, bedridden for a long time or those with poor muscle tome.( congenital or acquired)

Case 45

Initially look at the chest x-rays and make your impression. Two observations should be made on the chest radiograph. 1. there is widening of the mediastinum. Additionally, 2. there is a double density on the left side with  clear visualisation of the left aortic contour (Silhouette sign). With this input you should you consider an anterior mediastinal lesion. Classical differential diagnosis of anterior mediastinal lesion is remembered  with the pneumonic Terrible ‘T’. Our patient has a well defined cystic mediastinal lesion, without any solid components or enhancing areas. There appears to be a well defined lateral wall? compressed lung interface. This lesion can represent a mediastinal cyst of bronchial origin, thymic origin or mesenchymal origin like cystic hygroma. Despite the large size of cystic masses, often mediastinal structures are not disturbed.

Case 46

Series of radiographs are provided in a preterm neonate with respiratory distress. Patient had a progressively deteriorating course with the complication of sepsis. During the period of followup there was a sudden deterioration at the 2nd stage.

This is a classic presentation of a surfactant deficiency with hypoaeration of lungs leading to white-out lungs. There is an air bronchogram. Initially the abdominal radiograph was normal. Subsequently on surfactant therapy, lungs show an improved aeration. In the third radiograph there is a subtle crescentic epigastric radiolucency–an indication of early pneumoperitoneum. Trans-lateral radiographs at this stage are very useful in a sick neonate to show subtle peritoneal air. If overlooked, findings will become very evident as seen in the subsequent radiographs of our patient, wherein classical appearance of the pneumoperitoneum are demonstrated. There are well described signs of peritoneal air  -- Rigler sign, football sign, continuous diaphragm sign etc. Did you notice extension of air into the right scrotal region? In patients with patent processus vaginalis, intraperitoneal air extends to the scrotum. This is also true in patients with the indirect inguinal hernia.

Case 47

Chest radiograph and CT images of an adult patient with the hemoptysis is provided.

Chest radiograph is slightly misleading as it underestimates the disease. (Old case) some impression of lung hyperinflation is present. Observations on a CT are straightforward in the form of exudative and cavitary lesions with predominant upper zone distribution. Cavities in the right upper lobe are somewhat thin-walled, some show signet ring appearance. Exudative alveolar lesions are more predominant on the left. This may be one of the typical presentations of tuberculosis. Repeated examination for Mycobacterium in the sputum was negative in this patient. Instead growth of the sputum revealed fungus (aspergillosis)

Case 48

This is a 10-month-old child with a severe bronchiolitis leading to respiratory distress. Plain radiography of this patient had demonstrated generalised hyperinflation. Due to the severity of symptoms CT evaluation was performed. CT demonstrates areas of the focal hyperinflation/emphysema in the both lungs. There is distortion of the lung parenchymal pattern, showing focal areas of air spaces separated by fibrotic elements. If you observe both lungs are affected, the upper lobe shows relatively less changes. Hyperinflated air pockets have a tubular pattern probably of a peribronchial distribution. There is no pneumomediastinum or pneumothorax. CT appearances are not that of typical bronchiolitis, rather demonstrate scattered, global hyperinflation–leading to areas of focal lung destruction. Patient was followed up, and improved gradually on the nasal oxygen. The followup examination after a month shows reduction in the extent and pattern of lung changes. There is residual diffuse hyperinflation with few fibrotic components in the involved area. There is minimal amount of air trapping and resolution of cystic spaces.

This case presents a diagnostic challenge. Pathogenesis of the event is quite similar to that of congenital lobar hyperinflation. In our case findings have appeared later in life, following a severe respiratory infection (bronchiolitis) also there is a predominant destructive component, rather than simple hyperinflation. This pattern is also not that of obliterative bronchiolitis. Severe Bronchiolitis with the interstitial emphysema can present with part of these observations. However we do not see any signs of obvious pneumomediastinum. I have seen similar events taking place in a segment of lung in patients on surfactant therapy (reported case). However multifocal involvement following a respiratory infection is not frequently reported.

Case 49

This is a very interesting case of a 6-month-old child who had clinical presentation of an upper respiratory infection. You are all aware that thymic shadow is part of the paediatric radiography after the 3 months of age–lasting almost up to 2 years on plain radiographs. Occasionally a diagnostic challenge is encountered, issue of sorting out lung lesion versus a prominent thymus. What are your observations on these radiographs? Do you think there is a lesion in the lung or it is simply an enlarged thymus. You have lateral views to review as well. This patient has a prominent right lobe of thymus. Additionally radiographs demonstrate an opacity in the periphery of the right lower zone, which is in the lateral basal segment of the right lower lobe. Also in the course of followup there are diseases in the right upper lobe, adjacent to the thymus. Patient had pneumonia. Do you think the explanation is complete? Critical observer will notice radiolucency at the right lower zone( Pneumothorax) and subsequent chest tube insertion. Patient has staph pneumonia leading to pneumothorax. In the lateral view pneumothrax is causing radiolucency and sharp outline of adjecent landmarks.Thymus was just adding to confusion of interpretation

Case 50

Exploring COVID lung changes on plain films. By now it is very well established that the definitive way of making a diagnosis of SARS coronavirus is by PCR or similar specific lab tests. Radiology plays a role in the monitoring of the disease, monitoring of devices and tubes and anticipating complications. Previously unduly placed role of the CT in the diagnosis has reduced to a great extent. CT being the more rationally used for evaluation of complications, quantifying the lung changes, particularly fibrosis, excluding vascular disease and effects of vascular occlusion.

It is of a general interest to go through lung changes. Following illustrations show a spectra of plain film abnormality in COVID positive patients. Radiographic appearances could range from nearly normal appearance to characteristic abnormalities. One of the subtle observations that can be seen is a lung hypoaeration, persistently low lung volume on x-rays. Another less appreciated observation is a diffuse veiling/subtle ground glass density. This observation is less valuable on plain radiography because of technical variations. More evident radiographic abnormalities are structurally related to peribronchial disease, consolidation, fibrosis and pleural involvement. Typical patterns are : Reticulonodular pattern, reticular pattern, multiple lobar peripheral densities without air bronchogram, areas of dense consolidation with some volume loss are the other observations. Illustrations above show some of these patterns.

Case 51

I have included an additional set of images which represent the late phase of the disease. In the late phase some complications related to respiratory support may alter the appearance. The major respiratory support related to findings are air leak phenomena.  Observations of Late disease, including dense consolidation with volume loss (fibrosis) , pleural effusions, spontaneous air leak leading to pneumothorax, cavitations in the lung  and changes due to lung infarction. Global hypoaeration leading to airless lungs is a unique phenomena– quite similar to the changes seen in surfactant deficiency in neonates. One such illustration is also included in the sample. CT provides some specific information and some patterns mostly seen in the COVID patients. One patient with the pre-existing CHD is shown.Other diseases like  adult cardiac disease, exixsting abnormality due to infection, co-existing pulmonaty embilism and previous chronic lung disease may be seen in association with COVD lung disease.

Case 52

Frontal chest image, coronal reconstructions, and an axial image of the neck of an adult patient is provided. The challenge is to observe relavant the findings on the plain radiograph. What are your comments and observations? Did you notice mediastinal widening, particularly on the right side? 

Lung fields appear grossly clear. No gross cardiac enlargement. Any other important observations? I would like to focus your attention to the lower midline overlying the vertebral bodies. There is an area of radiolucency. Also, subtle widening of the left thoracic paraspinal line is noted. There are subtle findings; but no solid conclusions are possible. Combinations of the upper and lower mediastinal widening are often seen in diseases of the esophagus or thoracic spine.  There is something unusual about this radiograph in terms of technique. Technically oriented radiologists with a fancy for reconstructions will realize this. Now look at the rest of the images for completion of your observations. We have confirmed an abnormality in the lower esophageal region in the form of a central radiolucency around the ill-defined mass. This can represent a hiatus hernia or esophageal growth with focal air. In the superior mediastinum no obvious abnormality is appreciated. But certainly, the axial image at the lower neck demonstrates a cluster of lymph nodes in the left supraclavicular region. Also, there are heterogeneously hypodense areas in the right lobe of thyroid. This patient had lower esophageal carcinoma and left supraclavicular lymphadenopathy. Thyroid findings were incidental observations.

Case 53

The two provided radiographs frontal and lateral chest are real interpretational challenges. It is time for putting your best effort and interpretational skill. Do you have any idea about what is abnormal or likely pathology?  In my experience most of the younger radiologists will be in deep thoughts!

I hope you have noticed radiolucency on both sides of the lower thoracic spine, also overlying the spine itself. The second observation is a parenchymal lesion in the right upper zone. With this observation we can suspect some conditions like hiatus hernia, Morgagni hernia and occational entities like pneumo-mediastinum, esophageal rupture etc. After scrutinizing the lateral view do have any preferred choices? My bet was pneumomediastinum-esophageal rupture, as I noticed part of the air tracking anteriorly along the mediastinum. Contrast study confirmed extravasation of contrast from the oesophagus into the surrounding mediastinum. This was a case of a spontaneous distal esophageal rupture due to severe bout of vomiting.

AP and lateral contrast esophagogram images are shown. There is contrast reaching up to distal oesophagus, without passage of contrast into the stomach. Outline of the esophagus is somewhat irregular and bubbly. Lateral view also shows an irregular outline of  the anterior and posterior aspect of the esophagus. A pocket of air around the distal esophagus is also confirmed.  Often, spontaneous esophageal rupture tends to show contained appearance on contrast studies. Delayed images may show additional spillage of contrast in to surrounding areas. Esophagogram must be attempted only with the non-ionic iso-osmolar contrast to prevent untoward effects of contrast spillage.

Case  54

We have a chest radiograph of a patient who presented with pain and heaviness in the chest. Interpretation of this radiograph should not pose a challenge. Obviously, there is a mass in the right hemithorax, leading to the right lung collapse and the contralateral mediastinal shift. In view of non-visualization of the right fifth rib, lesion must be related to the missing rib. Additionally, you see that there is a loculated pleural collection. All these lead to an observation of chest wall mass arising from the rib. In young patients this is often due to an Ewing sarcoma or a round cell tumor. This entity goes by the special name Askins tumor. This patient had a biopsy confirmation and the representative axial CT images at the time of biopsy are present. Our interpretation of the chest is confirmed here. In addition, we do see some calcific elements in the lesion, either due to the residual bone from the rib or due to new bone formation. It is very difficult to verify the origin. Also note the enormous discrepancy in size of the right hemithorax in comparison to the left.

Case 55

You have chest radiographs, frontal and lateral views in a patient with fever. Diagnosis of a consolidation of the right upper lobe is very easy to make. What is special in this case? 

Regarding consolidation, I am sure you had noticed the air bronchogram. One more finding, inferiorly bulging horizontal fissure, is interesting indicating that this is pneumonia with increase in lung volume. Such pneumonias are common with haemophilus influenza or Klebsiella pneumonia. (occasionally pseudomonas). Anything else that we should look for. Yes.  signs of necrosis or cavitation. In addition, this patient also has a gross hepatosplenomegaly. Patients had common variable immune deficiency, hence increased susceptibility to systemic infection. Bulging fissures sometimes are better seen in the lateral view, like seen in this case. Likewise endobronchial lesions sometimes lead to increased volume in the distal lung due to secretions. (described as Drowned Lung)

Case 56

In this patient with fever, we have three images-- reconstructed CT Images. Obviously, I am trying to show certain focused imaging information, some anatomical and some related to pathology. Initially the anatomical information. Image 1 shows anterior junction line, a landmark showing the interface between both lungs anteriorly. Middle image demonstrates the azygo-oesophageal line, seen through the cardiac density. 

Did you make any observation as to the pathology? I assume that you have noted a somewhat asymmetrically prominent, lobulated left hilum. You may also suspect some subcarinal density. Second set of images are,CT sections, lung and mediastinal windows of the upper chest. Now you are able to make a complete diagnosis. There is a subtle, focal exudative lesion in the left upper lobe. And there are lymph nodes in the left hilum and in the prevascular region. Lymph nodes have somewhat radiolucent central part. These are typical nodes of tuberculosis. This combination of observations can be seen in primary complex, progressive primary pulmonary tuberculosis or in secondary–reactivation pulmonary Koch’s. The earlier description of the Ghon’s complex is a parenchymal lesion in the lung and the draining lymph node. Imaging is not often done at this stage.

Case 58

29-year-old male patient, investigated initially with a chest radiograph for a routine health check-up. Frontal and lateral chest radiography and CT images are available for interpretation. Do you have any active input? This is an Aunt Minnie case. There is a well-defined tubular opacity in the right mid zone, located anteriorly in the lateral radiograph. In asymptomatic patient some possibilities like subsegmental atelectasis, sequelae of inflammatory pathology, a vascular anomaly, or a rare developmental anomaly like bronchocele can be considered. CT examination of the chest will confirm the diagnosis. In this case confirms a well-defined tubular density in the middle lobe. The interesting element of chest radiograph is an abnormal hyperlucent area distal to the opacity. Indeed, this is a clue for a bronchial developmental anomaly with abnormal aeration of the distal lung, probably by collateral ventilation.Bronchocele can be congenital or acquired. Appearances in our patient is likely to be due to bronchial atresia, as there is an abnormal lung distal to the opacity. Acquired bronchocele are seen in bronchial asthma, APPA, cystic fibrosis etc.

Case 59

Chest radiographs of the young patient are provided. If you closely observe the radiographs, you will certainly see thin-walled cystic opacities in both lungs. Usual aetiology for such cysts in children is an acquired condition like a pneumatoceles secondary to Staph pneumonia, or cavitating lung lesions due to infection. In this patient there was no past history to indicate any established aetiology. Hence, condition may be a rare congenital disorder like cystic lung disease. Congenital cystic lung disease is extremely rare. Occasional instances are documented in polycystic kidney disease, congenital heart disease and respiratory anomalies. Interestingly cystic lung changes, much smaller in size are noted in adjecent lungs along the course of the hypertrophic collateral vessels in congenital heart disease. Such changes have a typical distribution pattern, located sub-plurally and adjacent to the hypertrophic vessels.

Case 60

Radiographs of a patient with suspected aspiration of foreign body is provided. Aspiration of a non-opaque foreign body poses a considerable challenge for detection. Sequelae of complete or partial obstruction, when evident, radiographs show some diagnostic observations. Occasionally findings are very subtle, in the form of a radiolucency or minor lung volume changes. In the past, decubitus radiography was used to identify partial bronchial obstruction. The principal behind radiography is that dependent lung deflates if the bronchial lumen is patent. Lung fails to show expiratory decrease if the bronchus is obstructed. In our patient the decubitus radiograph was negative for obstruction as dependent lungs show reduction in lung volume.

Case 62

This young patient had recurrent episodes of severe chest pains. Some of them were associated with fainting attacks. Some serial radiographs of the chest are provided, followed by a CT angiogram.

You might have noticed that the initial radiograph showed a wedge-shaped opacity at the right lower zone, this can be due to an atelectasis or a pleural shadow. Did you notice a small linear opacity at the left upper zone as well?  This was followed by additional chest radiographs which show somewhat rounded right upper lobe density. In addition, there are subtle bilateral basal opacities and the prominent pulmonary artery segment!! Combination of clinical history and radiographic findings should ring the bell --you should suspect pulmonary embolism with infarction. A CT angiogram confirmed a large thrombus in the right pulmonary artery and filling defect in the descending branch of the left pulmonary artery. This patient had recurrent pulmonary emboli.

Case 63

Plain radiographs of the chest and CTA examination are provided in a 31-yr- patient with severe breathlessness.

I am showing this radiograph to familiarise you with the finding of the severe pulmonary arterial hypertension on plain radiography. Obviously, you should be looking at the pulmonary arteries and the branches!!! You notice a large bulge in the region of the pulmonary artery segment, representing a hugely dilated main pulmonary artery. Also, you notice gross dilatation, elongation of the right pulmonary artery. These observations indicate dilated main pulmonary artery and proximal pulmonary arteries. Where is a left pulmonary artery? You will see this structure through the dilated main pulmonary artery!

Now some important secondary observations. I hope you noticed a right ventricular cardiac configuration. Also, you should note that there is abrupt cut-off of pulmonary arteries in the mid-lung fields. Peripheral lung fields show a somewhat radiolucent pattern without noticeable vascular elements. Also make a note that the aortic knuckle size is small and that the ductus is not enlarged. With these set of observations, it can conclude that there is severe pulmonary arterial hypertension with peripheral pruning of arterial branches – findings indicative of a severe pulmonary hypertension. It is important to exclude large left-to-right shunt like ASD or ductus. Once common causes are excluded, a possibility of a primary pulmonary hypertension can be considered. 

Case 64

A 6-year-old child had a brassy cough. Chest radiograph and CT images are provided. I am presenting this case because of an interesting plain radiographic observation. What is your analysis on this chest radiograph?  Did you think this is a pulmonary disease of middle lobe location or an extrapulmonary lesion? Points to observe are the obliteration of the right cardiac border, vessel overlay sign and absence of the air bronchogram. The lateral border of the lesion is sharp. The superior margin is indistinct. All these observations point to an anterior mediastinal mass. Do you agree with me? Lateral view confirms our observation. CT images make an additional contribution by showing an enhancing mass with some cystic areas. Interface with the lung is sharp. Interface with the vascular structures of the mediastinum is well-defined at most of the places, although in close approximation. Some minor atelectasis is noted in the visualised lungs. Differential diagnosis is somewhat straightforward. Thymic masses, mediastinal teratomas lead the list. This patient had a germ-cell tumour.

Case 65

Patient is a 22-month-old boy, who was a co-passenger in a high velocity road traffic accident. Multiple chest x-rays in sequence are provided. Initial examination was performed on the day of examination with additional radiographs at quick intervals. There are subsequent follow-up radiographies and a CT examination. I want you to scrutinise these radiographs to make logical conclusions. 

In the initial examination you will notice ill-defined opacities in the right lower zone. Do you see a slight radiolucency around the cardiac shadow? In fact, you should suspect subtle pneumomediastinum. On follow-up, there is minimal increase in lung densities, however pneumo-mediastinum appears to persist. In the later examination of the 14th, you notice that lung opacities have decreased and there is resorption of pneumomediastinum.

Meanwhile there is a CT examination done on the day of RTA. Examination confirms pneumomediastinum and a subtle left pneumothorax.  Changes are seen in the right lower lobe in the form of irregular cavities with fluid levels and some additional ill-defined subpleural airspace opacities. Similar changes are also noted at the periphery of the left lung. All these findings are lung contusions in various phases of evolution. Ultimately most of these changes resolve without leaving much residual lung changes

Case 66 :  Non-pathological  observations on routine chest radiography      

Case 67

Next patient is an intriguing radiological illustration. a 27-yrs- male had episodes of haemoptysis and chest discomforts. I am providing you with a set up for chest radiographs and corresponding CT. Some additional images of this patient are also illustrated elsewhere with a slightly different perspective. [ultrasound section.(case 31)]

In the chest radiograph there are subtle ill-defined pulmonary opacities in mid zones. Some of them are apparently pleural-based or peripherally located. The remaining lungs appear hyperinflated. There is an unusual cardiac contour with a predominant right-sided cardiac bulge. Also, there is some suggestion of a very prominent left upper mediastinal shadow. I hope you have noted these observations. Now proceeding with the CT interpretation. The left lung is relatively small and shows multiple cavities in the upper lobes. There are tree-in-bud opacities as well as ill-defined alveolar opacities in the upper lobes. There are similar nodular lung changes on the right side. The lung changes suggest a possible infective aetiology like tuberculosis. Did you look at any other observations?  This patient has a contrast-enhanced CT of the thorax including abdomen. There are unexpected observations like situs inversus in association with abnormal vessels. To start with there is a right aortic arch and the left descending aorta. There appears to be an abnormal vessel (venous) in the region of the left renal hilum, part of which crosses the midline to the right side, behind the aorta– further continuing as a azygos vein.  The venous structure in the left renal region continues as left inferior vena cava, joining the right atrium. (3D reconstructions).  Is it a case of interrupted left inferior vena cava in association with the situs inversus? Is it heterotaxia syndrome? Now it is time to go through the sonography section to have some more input about the visualised vascular structures.

Case 68

Set of examinations, frontal and both decubitus views in a child with suspected FB are provideded. When airway signs are present in a suspected non-opaque FB localisation is easy. Problem comes  when clinical supecion is high and no obvious clues on frontal radiography. In co-operative children expiratory film can be obtained. In those who could not co-operate, a decubitus views are a good choice.Non-obstructed dependant lungs deflate when placed in a decubitus position. Examination was negative in this child. With  wide availabalility of CT, these techniques are infrequently used.

Case 71 : 47-old-female with exersional dysapnoea.

Case 71

A 50-year-old female with the dyspnea on exertion was investigated with the radiography and subsequently CT chest.

Two examinations performed at short intervals are provided.What is your impression of plain radiography?  The striking observation on these radiographs is the relative low volume of the lungs. In addition, there are reticulo-nodular shadowing of both lungs, symmetrically distributed in all the zones. There is an opacity at the medial part of the right mid zone probably representing an area of atelectasis. Reticular nodular/microcystic lung changes in a low volume lung indicate interstitial lung disease. Also note widening of the subcarinal angle with an apparent impression of the left atrial enlargement. CT images show two important observations. One is the honeycombed pattern of lung changes at the lower lobes, showing some predilection for subpleural airspaces. This finding is generally noted in patients with the ‘usual interstitial pneumonia’.(UIP) The second observation is the more severe lung changes in the mid zones with the lung atelectasis-fibrosis and confluent shadowing. These changes are also seen to extend to the right upper lobe. Over observation suggested a fibrosing lung disease with the background of predominant interstitial fibrosis. Such appearances can be grouped into 1. specific disease processes where etiology is known and 2. Non-specific group. 

Specificetiology groups usually have an infective, inhalational, toxic, autoimmune, or inherited basis.

When cause is not determined, the idiopathic interstitial pneumonia (IIP) should be considered:

• Usual interstitial pneumonia (UIP): idiopathic pulmonary fibrosis

• Cryptogenic organizing pneumonia (COP): previously termed BOOP

• Non-UIP IIP

  • non-specific interstitial pneumonia (NSIP): non-smokers

  • respiratory bronchiolitis-interstitial lung disease (RB-ILD): smokers

  • desquamative interstitial pneumonia (DIP): end-state of RB-ILD

  • lymphoid interstitial pneumonia (LIP): women

  • acute interstitial pneumonitis (AIP)

• other entities

  • Combined pulmonary fibrosis and emphysema (CPFE)

Mnemonic: All Idiopathic Chronic Lung Diseases aRe Nonspecific  ( Radiopedia)

For interpretation of the HRCT pattern of various lung diseases with possible differential diagnosis, radiology residents can visit Radiology Assistant for detailed information.

Case 72 : 12-yr-male with wheezing and occasional blood tinged sputum

Case 72

This is a 15-year-old male presented with the wheezing and occasional blood-tinged sputum. These images are shared as the findings are classic. This might be a good case for building a visual image library for aspergillosis. You are provided with CT chest images at different levels. You notice predominantly peripheral bronchiectasis. Minimal associated parenchymal changes are noted around some bronchiectatic lesions, either due to minimal bleeding or superadded infection. Also, you note few subpleural cystic lesions, which are generally not a general picture of aspergillosis. Manifestations of aspergillosis in immunosuppressed patients may be quite remarkable. Classic patterns of pulmonary aspergillosis are:

1. Saprophytic aspergillosis (fungus ball)

2. Hypersensitivity reaction. (Allergic BP aspergillosis) - the variety seen in our patient, asthmatic

3. Semi-invasive aspergillosis (necrotizing) - associated with the debilitating illness, diabetes, alcoholism, steroid therapy et cetera)

4. Invasive aspergillosis –seen in immunosuppressed patients

5. Angio invasive aspergillosis –exclusively in immunosuppressed patient.

(Ref: Spectrum of Pulmonary Aspergillosis: Histologic, Clinical, and Radiologic Findings: Tomás Franquet, Nestor L. Müller, Ana Giménez, Pedro Guembe, Jesus de la Torre, and S. Bagué  RadioGraphics 2001 21:4, 825-837 )

Some examples illustrating disease pathology is shown below.

Case 73 : 3-yr-child operated for a septal defect, recurrent URTI

Case 73

A 3-year-old patient with the history of operated AVCD is evaluated for recurrent chest infection. This case shows a close interrelation between congenital cardiac disease and lung changes.Patients with Left-to-right shunts often predispose to recurrent chest infection. If associated with syndromes (like Down syndrome) they are more prone for recurrent chest infection. In this patient you have two main observations. 1. Cardiac abnormality is visible on the plain film in the form of cardiomegaly, dilated main pulmonary artery and enlargement of the atrial chambers. Evidence of cardiac surgery is noted. Unfortunately, this patient did not benefit much from the surgical procedure. This observation is confirmed in the CT images which shows evidence of persistent severe pulmonary arterial hypertension. Note the discrepancy between the central and peripheral pulmonary artery branches–an indication of severe pulmonary hypertension. 2. The second element to look for is the abnormal lung aeration and areas of atelectasis. This has resulted from the recurrent chest infection. Also noted is the airway compression involving the left main bronchus and somewhat compressed appearance of the trachea -- indicating some element of broncho-tracheomalacia.

Case 74 : 14-yr-male with chronic cough, greenish sputum and clubbing.

Case 74

A14-year-old male had recurrent chest infections and a productive cough. Plain radiograph of the chest and sinuses and CT imaging was performed. With this case I am adding one more aspect of the recurrent chest infection for consideration. The appearance on the chest x-ray is bizarre. There are bilateral lung lesions along the medial aspect of lower zones, enveloping the cardiac contour. This reflects disease in the middle lobe lingula and medial basal segments of the lower lobes. Additionally, the patient appears to have mucosal thickening in the paranasal sinus. Combination of these two observations presents a group of conditions like cystic fibrosis, Wegener’s granulomatosis, pneumoconiosis, and immune deficiency syndromes like hypo-gammaglobulinemia. The range of differential diagnosis certainly calls for elaborate laboratory testing. In this case the patient had low-gamma globulin levels. CT imaging is complementary to the plain film and demonstrates distribution of the disease. There are atelectatic areas and areas of bronchiectasis. Disease is mainly around the cardiac contours, sparing the periphery - on observation not easy to explain.

Case 75 : 6-month child with recurrent chest infection.

Case 75

A 6-month-old child with recurrent chest infection and pulmonary shadowing on plain radiography was investigated with CT.

Patient had a clinical diagnosis of recurrent bronchiolitis. CT observations reflect persistent airway abnormality. Although initially bronchiolitis affects the terminal bronchioles, in the later stage, disease becomes more generalized and larger airways are affected. Mucous plugging of the airways with resultant atelectasis is a common feature. In this patient we see complete collapse/consolidation of right upper lobe. Also, multiple subsegmental atelectasis is noted lower lobes, middle lobe and lingula. Trachea and proximal bronchi appear normal, as shown in the coronal and sagittal reconstructions. With good supportive care complete expansion of the lung is likely.

Case 76 : 18-yr-male, known case of bronchial asthma.

Case 76

This young adult, known case of bronchial asthma presented to the hospital at multiple times. Present asthmatic patients, under good medical control, rarely manifest these observations. In this patient what we are observing is sequel of episodes of mucous plugging, an initial radiograph demonstrating a left upper lobe collapse, another demonstrating right lobe subsegmental collapse and the third one showing multifocal collapse in the upper and lower lobes on the right side. Generally, with effective treatment these lung segments expand. If not properly dealt with, complications like fibrosis may take place. Also, sputum should be thoroughly evaluated for Aspergillus.

Case 77 : 60-yr-old with dysapnoea at rest and heaviness in the chest.

Case 77

60-yr-old patient with the dyspnea at rest and heaviness in the chest is investigated with a CT imaging. Plain radiography and the two sets of CT images at 4-month intervals is provided. As far as a chest radiograph is concerned, interpretation is somewhat simple. We have homogeneous opacification of the left hemithorax with mass-effect. There is a rounded soft tissue density in the right upper lobe merging with the mediastinal/hilar contour. Rest of the right lung appears normal. Grossly the bony cage appears to be within normal limits. Obviously, the outcome of interpretation of this chest radiograph boils down to either a massive pleural collection or a large pulmonary mass with pleural components. 

On CT examination a large mass confluent with the mediastinum with encasement of the aorta and great arteries is visualized. While the mass is predominantly in the upper chest, causing displacement and compression effect on the lung below. Also, sequelae of occlusion of the innominate vein and subsequent collateral venous collaterals are visualized in the upper dorsal peri-spinal region. Patient was confirmed to have a squamous cell carcinoma. Subsequently the patient was treated with chemotherapy. We have a follow-up examination after 4 months showing partial reduction in the size of the mass which is now limited to the left upper thorax. Note that on the chest radiographs, the mass has decreased in size and there is visualization of the left lower lobe. Lung windows of the remaining lung fields demonstrate exaggerated interstitial shadowing, indicating possible lymphangitic spread. Also, there is a small cavitating ill-defined lesion at the right upper lobe. Note that there is very little pleural component. This is a case of advanced bronchial neoplasm with mediastinal and contralateral spread.

Case 78 : 27-year-old female presented with recurrent productive cough and clubbing. 

Case 78

27-year-old female presented with recurrent productive cough and clubbing. Chest examination was abnormal and showed suspicion of multiple cavities. CT evaluation was performed. There is no diagnostic challenge in this case. There are multiple cavitary lesions in the upper lobes, middle lobe and lingula. Extensive alveolar ill-defined opacities are noted around the cavities. There are abundant areas where tree-in-buds are visualized. Some involved areas show atelectasis and consolidation as noted in the middle lobe (air bronchogram). You might have guessed; etiology lies between two similar entities 1. Extensive cavitary tuberculosis (post-primary) or a close mimic, Cystic fibrosis. This patient had cystic fibrosis gene and had florid secondary infection with pseudomonas infection leading to extensive lung changes. Notice that differentiation from tuberculosis is not very easy, although distribution in the middle lobe lingula in the combination right upper lobe are often seen in cystic fibrosis.

Case 79

This patient is a neonate with respiratory distress, diagnosed as the surfactant deficiency syndrome and treated accordingly. This examination is relatively old when surfactant replacement therapy was just initiated. There are series of x-rays from day one to subsequent follow-up for a few months. I am showing these images just to give you a glimpse of a disease pattern that was very common in the past.

The first image is a white-out lung –A terminology used to describe completely collapsed airspaces in the surfactant deficiency syndrome. You can appreciate air bronchogram in collapsed lungs and life support devices of the baby. With the conservative management with the surfactant replacement, the patient did make some recovery. Notice that radiography recovery appears incomplete showing uneven lung aeration, persistent subsegmental atelectasis involving both lungs. In the later period of follow-up, uneven lung aeration becomes more evident with fibrotic opacities interspersed. This describes the entity of bronchopulmonary dysplasia.(BPD) Presently described as a chronic pulmonary disease of prematurity. Earlier description of the disease, dividing appearances into 4 stages is not very relevant now. The entity itself has become less common due to improved neonatal care and the more specific management of the surfactant deficiency.

Case 80

6-month-old child with recurrent chest infection. Chest film and CT evaluation of the chest are provided. What is your opinion on the chest radiograph.? Is the radiograph normal or do you have some other observation?  

 Well, you should notice relative radiolucency of the left upper lobe and part of the right upper zone. Rest of the lungs appear to have minimal relative increase in density. Did you observe loss of contour of the right atrium? A positive silhouette sign.  On the CT images observations are easy to appreciate. Images are not very great, although they show aeration abnormality involving most of the lungs, sparing part of the lobes. Also notice that the branching pattern of the pulmonary arteries are very irregular. This indicates that observation is not just due to aeration abnormality. There is subsegmental atelectasis of the medial segment of mid lobe. What is your overall impression from these images?

Here we are dealing with a case of bronchiolitis obliterans.  Certain severe forms of bronchiolitis progress further and result in obliteration of the pulmonary arterioles/distal ramifications. In imaging studies these manifest as radiolucent areas with pulmonary arteries showing irregularity,tortuosity of branches, sudden vessel cut-off and asymmetry of arterial distribution etc. Lung biopsy might show obliterative bronchiolitis.(not often performed) Unilateral form of such a disease is known as Mcleod’s syndrome / Sweyer James syndrome

Case 81

Patient is a term neonate, 3-week-old presenting with mild respiratory difficulty. Plain radiography revealed a somewhat small, relatively opaque right lung. Lungs shadows were persistent on follow up. Subsequently the patient underwent CT examination. What is your impression on the CT? This case is simple and a similar case was illustrated on an earlier occasion. We notice hypoeration of both lung bases with areas of multiple subsegmental atelectasis. Additionally, there are small cystic areas in the right lower lobe and ? left lower zone. This raises the possibility of a cystic adenomatoid malformation of the lung. In this patient likely to be associated with minimal lung hypoplasia. Patient was treated conservatively and remained asymptomatic.

Case 83 : 50-yr-male with breathlessness ,cough and chest pain

Case 84

3-chest radiographs are presented; two in the frontal projection and one in the lateral projection in a 60-year-old patient with exertional dyspnea.

Observations on these radiographs are somewhat simple. There is hyperinflation of lungs with increased radiolucency of the retrosternal space. But there are few subtle findings like focal (lobar) areas of hyperinflation with thin walls noted in the lower zones in association with some linear shadows at the left upper zone. The next set of CT images confirms this observation. Basically, there are bullous lung lesions with thin imperceptible walls in both lungs. Lower zone lesions have posterior distribution (lower lobes) and the upper lesions are in upper lobes. These findings are consistent with the bullous emphysema rather than pan-acinar emphysema. There is an image demonstrating a color map of densities. Dense areas, areas with the vascular structures are shown in the red, mostly seen in the medial and central distribution. Severely hyperinflated areas are shown as brown with intermittent aeration areas are demonstrated in the combination of the violet and pink. Color maps can be used to highlight some changes in the lungs. It is very important to realise that any dense areas(Vascular or parenchymal shadows) have the same colour pattern. Thus uneven lung densities do not represent perfusion pattern.

When the bulla enlarges more than one third of the lung, it is referred to as giant emphysematous bulla; often seen in association with vanishing lung syndrome. Rupture of the bulla may lead to pneumothorax. Other complications of bulla are infection, hemorrhage. Bilateral multiple bullae may be associated with conditions like Marfan’s syndrome, arterial tortuosity syndrome and alpha antitrypsin deficiency.

Case 85

This is a 30-year-old male patient with abdominal pain with clinical diagnosis of pancreatitis. Chest radiographs, two days apart are provided. In the initial radiograph there are bilateral pulmonary densities, more extensive on the right side. Pleural fluid is evident, but part of the right lung density has a sharp upper margin. Subsequently the patient had a pleural drainage. In the follow-up radiograph we have some interesting observations. While the pleural fluid has regressed significantly there is a residual well-defined oval opacity in the right mid peripheral lung field. Also, there is persistence of a diffuse opacity in the right mid and lower zone with a sharp upper margin. What do you think is the likely possibility? Is there a mass lesion underlying the pleural fluid?

Set of radiographs, plain axial CT and reconstructions obtained in this patient a week earlier is presented. You notice that this patient has a left-sided pleural fluid with collapse of the left lung. There is no significant pleural fluid on the right side. Fluids appear to have a tendency for loculation. No obvious mass lesion is noted in the right lung. Now what is your general impression on the opacities demonstrated in the initial radiographs? Do you think there is a new mass lesion or there is a possibility of pseudo mass like appearance due to encysted pleural fluid pockets?

To make observations simpler, a series of radiographs taken in this patient over a period of 10 days is provided. You notice that initially the patient had a left pleural fluid with some loculation. Subsequently the fluid was drained, and new pleural effusion developed on the right side. Also, there was successful drainage of the right pleural fluid pocket. Later, the patient developed recurrent right sided opacities, including an oval mass like lesion in the mid/lower zone. Note that the patient has two pleural drainage catheters in the seventh radiograph. The radiograph no 7 and 8 was presented as an 'initial set'. This patient has large pleural loculations in the horizontal and oblique fissure. Pleural loculation in the horizontal fissure is seen as a mass. Collection in the oblique fissure is seen as an opacity with a sharp upper margin. Such loculation tends to occur in patients with congestive failure, known as a phantom tumor, as they completely resolve following the treatment of the cardiac failure.