Extramedullary hematopoiesis
Compensatory mechanism to increase bone marrow function Seen in thalassemia, hereditary spherocytosis, sickle cell anemia Typically in lower thorax Symmetrical, bilateral Marrow bursts out of bone and appears as soft tissue mass May have fatty content within
Lateral thoracic meningocele
Rare Redundant spinal meninges protrudes through intervertebral foramen Contains CSF Asymptomatic Difficult to distinguish from neurogenic tumors
Pulmonary edema
Increased hydrostatic pressure Cardiogenic Heart disease – left ventricular failure, mitral valve disease, left atrial myxomaPulmonary venous disease – veno occlusive disease, mediastinal fibrosisPericardial disease – constrictive pericarditis, pericardial effusionDrugs – anti-arrhythmic, beta blockers Non-cardiogenic Renal failureIntravenous fluid overload Neurogenic Decreased colloid osmotic pressure HypoproteinemiaRapid re-expansion of lungTransfusion of crystalloid fluid Increased capillary permeability Aspiration…
Patterns of edema and pulmonary venous hypertension
Grade 1Vascular redistributionmm of HgGrade 2Interstitial edemamm of HgGrade 3Alveolar edemamm of HgAcute12-1920-25>25Chronic15-2525-50>30
Pulmonary venous hypertension
Left ventricular failureMitral valve diseaseLeft atrial myxomaFibrosing mediastinitisPulmonary veno-occlusive disease
Pulmonary oligemia
Tricuspid atresiaTricuspid stenosisEbstein anomalyPulmonary valve stenosisPulmonary artery atresiaTetralogy of FallotTGA with pulmonary valve stenosis
Pulmonary plethora
ASDVSDPDATGASinus venosus defectAnomalous pulmonary venous drainageDouble outlet ventricleSingle ventricleSystemic to pulmonary artery shuntsVein of Galen malformation
Acute respiratory distress syndrome
Pulmonary causes Pulmonary contusionAspiration of gastric acid contentsSmoke inhalationNear drowningPneumoniaFat embolism Extra-pulmonary causes BurnsHypovolemiaHypoperfusionMassive blood transfusionSystemic sepsis
Bilateral upper lobe lung fibrosis
TuberculosisSarcoidosisHistoplasmosisAllergic bronchopulmonary aspergillosisChronic extrinsic allergic alveolitisAnkylosing spondylitisProgressive massive fibrosisIdiopathic pleuroparenchymal fibroelastosis
Centrilobular lung nodules
Subacute hypersensitivity pneumonitisRespiratory bronchiolitis-interstitial lung diseaseDiffuse panbronchiolitisEndobronchial spread of tuberculosis or bacterial pneumoniaCryptogenic organizing pneumonia
Solitary pulmonary mass
Bronchial carcinomaBronchial carcinoidGranulomaHamartomaMetastasisChronic pneumoniaHydatid cystPulmonary hematomaBronchoceleFungus ballMassive fibrosisBronchogenic cystSequestrationArteriovenous malformationInfarct
Mediastinal masses
Anterior Thymoma Lymphoma Germ-cell tumor Goitre Middle Lymph nodesDuplication cystArch anomalyEsophageal mass Posterior Neurogenic Bone and marrow
Focal bulge of diaphragm
Partial eventrationDiaphragmatic herniaDiaphragmatic tumorPleural tumor Pulmonary tumorFocal diaphragmatic dysfunctionFocal diaphragmatic adhesions
Elevated diaphragm
Bilateral Supine positionPoor inspirationObesityPregnancyAbdominal distension – ascites, intestinal obstruction, abdominal massDiffuse pulmonary fibrosisLymphangitis carcinomatosaDisseminated lupus erythematosusBilateral basal pulmonary emboliPainful conditions after surgeryBilateral diaphragmatic paralysis Unilateral Posture – lateral decubitus positionGaseous distension of stomach or colonDorsal scoliosisPulmonary hypoplasiaPulmonary collapsePhrenic nerve palsyEventrationPneumonia or pleurisyPulmonary thromboembolismRib fracture and other painful conditionsSubphrenic infectionSubphrenic mass
Pneumothorax
Spontaneous Airflow obstruction AsthmaChronic obstructive pulmonary diseaseCystic fibrosisPulmonary infectionCavitating pneumoniaTuberculosisFungal diseaseAIDSPneumatocelePulmonary infarctionNeoplasmMetastatic sarcomaDiffuse lung diseaseHistiocytosis XLymphangioleiomyomatosisFibrosing alveolitisHereditaryMarfan syndromeEndometriosis Traumatic Iatrogenic ThoracotomyThoracocentesisPercutaneous biopsyTracheostomyCentral venous catheterizationNon-iatrogenicRuptured esophagus/tracheaClosed chest traumaPenetrating chest trauma
Unilateral opacified hemithorax
Pleural effusionConsolidationCollapseLarge tumor FibrothoraxPneumonectomyLung agenesis
Congenital venolobar syndrome
Scimitar syndromeLung hypoplasia and ipsilateral anomalous systemic venous drainageAnomalous right pulmonary vein drains into IVC, hepatic or portal vein, coronary sinus or right atriumMost asymptomaticLeft-to-right shunt can lead to pulmonary hypertension Imaging Similar to isolated lung hypoplasia – increased opacity of one hemithorax, mediastinal shift, contralateral lung hyperinflationAnomalous vein – tubular shadow, runs to base…
Congenital lobar hyperinflation
Bronchial abnormalityCheck-valve mechanism, causes progressive hyperinflation of affected lobeTends to reduce with time in asymptomatic patientsNeeds excision in symptomatic children Imaging Left upper lobe (42%)Right middle lobe (35%)Radioopacity in affected lobe in postnatal period due to fluidWith time, hyperinflation with hyperlucency of affected lobeCT: rules out other causes – vascular anomalies, compression of bronchi or…
Idiopathic pulmonary hemosiderosis
Rare, unknown etiologyChildren 0-10 yearsEpisodic intra-alveolar hemorrhageHemoptysisIron-deficiency anemiaAirspace opacities on plain filmRepetitive bleeding leads to lung fibrosis Read more Saeed, Muhammad M., et al. “Prognosis in pediatric idiopathic pulmonary hemosiderosis.” Chest 116.3 (1999): 721-725.
Granulomatous polyangiitis
Earlier called Wegener’s granulomatosisPrimary (idiopathic) small vessel vasculitidesNecrotizing granulomatous inflammation of small vessels of upper and lower respiratory tractM=FAny age of presentationLungs affected in 90% of casesCough, dyspnea, pleuritic chest pain, hemoptysisc-ANCA directed against proteinase-3 is positive Imaging Chest XrayBilateral nodules or massesNodules from few mm to 10 cmNo zone predilectionNodules larger than 2 cm…
Chronic eosinophilic pneumonia
Protracted courseMore symptomaticMild to moderate eosinophiliaElevated serum IgE in peripheral bloodGood prognosisPatients respond to steroids Imaging Chest XrayPatchy non-segmental consolidationInvolves mid and upper zonesOpacities peripheral and parallel to chest wall – photographic negative of pulmonary edemaCTSame findings as plain film, more apparent in CTDifferential: organizing pneumonia. Nodules are more common in organizing pneumonia rather than…
Alveolar proteinosis
Accumulation of periodic acid Schiff positive lipoproteinaceous material in alveoliDue to abnormal surfactant clearance from lungsFault in GM-CSF signaling Primary – idiopathic due to anti GM-CSF antibodiesSecondary – dust inhalation, infections, myelodysplasia, lymphoma, myeloid leukemia20-50 years M>FMore in childrenDefinitive diagnosis: bronchoalveolar lavage, biopsy Imaging Chest XrayNonspecificBoth lungs affectedAirspace opacification predominantly in central lung – bat’s-wing appearanceCTCrazy paving…
Alveolar microlithiasis
Deposition of tiny stones mainly made of calcium phosphate in air spacesMutations in SLC34A2 gene. This gene codes for sodium dependent phosphate transporter in type II alveolar cellsCauses phosphate accumulation30-50 years ageAsymptomatic at presentation Imaging Chest XrayWidespread discrete high density opacities (resembling sand grains)When profusely involving lungs, similar to a white out appearanceObscuration of heart…
Simple pulmonary eosinophilia
Loffler’s syndromeElevated eosinophil count in peripheral bloodAssociation with parasitic infection – Ascaris lumbricoides Imaging Chest XrayFleeting transient infiltratesUni or bilateralResolution of opacities within days and maximum one monthCTGround-glass opacities, consolidationPeriphery of mid and upper lung zonesSingle or multiple acinar nodules Read more Jeong, Yeon Joo, et al. “Eosinophilic lung diseases: a clinical, radiologic, and pathologic…
Limitations of portable chest radiography
Scattered radiationInability to capture all relevant informationSignificant underexposure increases noise and reduces contrast resolutionShorter focus-detector distance causes undesirable magnificationHigh kV techniques not possible, longer exposure times needed, hence more motion artifacts
Modified Stocker Congenital Pulmonary Airway Malformations Classification
Type Description 0 Incompatible with life 1 Commonest (>65%) Several large intercommunicating cysts (up to 10 cm) Mediastinal shift common 2 10-15% Smaller than other types Small evenly sized cysts (up to 2 cm) Other associated congenital abnormalities 3 8% cases Large solid appearing lesion with microcysts (<5 mm) Causes mediastinal shift Poor prognosis 4 10-15% Large cysts, indistinguishable from type 1
Pleural effusion in children
Causes Infection Parapneumonic Empyema – streptococcal or staphylococcal Tuberculosis Neoplasm Leukemia Lymphoma Metastasis: Wilms PNET Mesothelioma Inflammatory Pancreatitis (small, left) Fluid overload Low albumin states Cardiac failure Severe sepsis Trauma Hemothorax Congenital Diaphragmatic hernia Chylothorax – lymphangiectasia / lymphangiomatosis
Bilateral symmetrical elevation of diaphragm
supine positionpoor inspirationobesitypregnancyabdominal distension (ascites, intestinal obstruction, abdominal mass)diffuse pulmonary fibrosislymphangitis carcinomatosadisseminated lupus erythematosusbilateral basal pulmonary embolipainful conditions (after abdominal surgery)bilateral diaphragmatic paralysis
Unilateral elevation of diaphragm
posture – lateral decubitus position (dependent side)gaseous dissension of stomach or colondorsal scoliosispulmonary hypoplasiapulmonary collapsephrenic nerve palsyeventrationpneumonia or pleurisypulmonary thromboembolismrib fracturesubphrenic infectionsubphrenic mass
Lines and tubes in neonates
endotracheal tube tip varies with head and neck motiontip should be above carina consider chin position nasogastric tube within stomach nasojejunal tube include weighted tipside hole at duodenojejunal flexure umbilical arterial line tip between T6 and T9course inferiorly within umbilical artery into internal and common iliac arteries, then into aorta umbilical venous line tip at…
Neonatal pneumonia
occurs perinatallyascending infection from vaginatransvaginally during birthhospital acquired infection in post natal periodprolonged rupture of membranes is a known riskinfant swallows or aspirates infected amniotic fluid or vaginal tract secretionsGroup B streptococcus most common organism imaging severe acute symptoms first 24-48 hours coarse bilateral asymmetrical alveolar opacification with or without interstitial change pleural effusionpulmonary hyperinflationmild…
Transient tachypnea of the newborn
retained fetal lung fluid / wet-lung syndrome normally fluid cleared from lungs at or immediately after birth by pulmonary lymphatics and capillaries normal clearance delayed in this conditionseen post caesarean section, hypoproteinemia, hyponatremia, maternal fluid overload seen in small hypotonic sedated infants with precipitous deliverymild to moderate respiratory distress without cyanosis in first few hourscomplete…
Idiopathic respiratory distress syndrome
hyaline membrane diseaseaffects premature infant < 36 weeks deficiency of lipoprotein pulmonary surfactant and structural immaturity of lungs pathophysiology lipoproteins produced by type II pneumocytesconcentrated in cell lamellar bodiesthen transported to cell surface and expressed on alveolar luminal surfacelipoproteins combine with surface surfactant proteins A, B, C and D to form tubular myelintubular myelin lowers…
Normal lung development
26 days to 6 weeks (embryonic phase) lung bud develops from primitive foregutbud divides to form early tracheobronchial tree 6 to 16 weeks (pseudoglandular phase) airway development up to terminal bronchiolesdeficient alveolar saccules 16 to 28 weeks (canalicular or acinar phase) multiple alveolar ducts develop from respiratory bronchiolesducts lined by type II alveolar cells that…
Neonate chest
AP and transverse diameter equal, giving a cylindrical configurationrotation assessed by comparing length of anterior ribsnormal cardiothoracic ratio up to 0.6variable thymic sizethymic involution: prenatal or postnatal stress, hyaline membrane disease, corticosteroid treatment known artefacts: hole in incubator top looks like pneumatocele. skin fold mimic pneumothorax
Imaging pleural effusion
chest radiograph small subpulmonary effusions not seenminimal fluid best detected in lateral decubitus radiograph200 to 500 ml fluid needed for blunting of posterior and lateral costophrenic angleshomogenous opacification of lower chestobliteration of costophrenic angle and hemidiaphragmsuperior margin of opacity concave to lung and higher laterally than mediallyabove and medial to meniscus, hazy increase in opacity…
Pleural effusion
Types of effusion transudateexudate (thin or thick)blood chyle bile CSFiatrogenic fluids Bilateral pleural effusion tend to be transudatesdue to rise in capillary pressure or fall in blood proteinsexudative bilateral effusion: metastasis, lymphoma, pulmonary embolism, rheumatoid disease, SLE, post-cardiac injury syndrome, myxedema and some ascites related effusions Right sided effusions ascitesheart failureliver abscess Left sided effusions…
Chest wall tumors
indents pleura, form obtuse angles and tapered borderosseous origin lesions: grow along or destroy underlying bonelymph or neural origin: paraspinal or intercostal location with bone erosionbenign lesions: rib erosion, separation, notch like remodeling without cortical destruction.malignant and inflammatory lesions: bone destructionbone destruction in adults: metastases (breast, lung or kidney), multiple myeloma, lymphoma, sarcoma or primary…
Normal chest Xray
In this series of short and crisp audio lectures on YouTube, I elaborate a systematic approach to reading the chest Xray. This approach will enable one to focus on all areas without delving too deep into the fine details.
Lung consolidation
Findings Homogeneous air space opacity involving the right lower zone with fairly well defined margins. The contours of the right hemi-diaphragm and the right heart border are distinct. The costophrenic and cardiophrenic angles are defined. Linear lucencies seen within the opacity radiating from the hilum consistent with air bronchograms. No evident lung volume loss. Rest…
Cystic bronchiectasis
Cystic bronchiectasis with active infection #Foamed #FoamRad
Primary and secondaries of lung
Clinical presentation 65 year old lady with generalized weakness since 3-4 months, persistent cough and breathing difficulty. CT https://www.youtube.com/watch?v=vepz_laCwAU https://www.youtube.com/watch?v=K4J6-f041TQ https://www.youtube.com/watch?v=qKpoHGIWSFI Findings A well defined heterogeneously enhancing intraparenchymal mass lesion is seen involving the anterior segment of left upper lobe with associated segmental bronchial cut off and secondary collapse. secondary reduced volume of left lung…