Many systematic approaches of chest Xray interpretation are proposed in the literature,
and most radiologists choose and adopt one.
They are so many elements and superimpositions of structures on a chest Xray that we believe those routine reviews are useful even for the more experienced radiologists: missing a rib lesion or an apical mass can easily happen in the high volume clinical imaging environment most radiologoists live in nowadays.
We chose simplified check-lists both for chest XRay and CTscan reporting,
and applied them systematically to all of our cases.
Clinical data is presented the way it was available on the request forms.
All CT scans have been performed within a maximum of one week apart from the chest XRays provided in our review.
USEFUL ABBREVIATIONS
CXR: chest X ray
CT: computer tomodensitometry
LLL: left lower lobe
LUL: left upper lobe
RLL: right lower lobe
RLL: right upper lobe
ML: middle lobe
CASE 1
REQUEST FORM : 31 year-old man presenting with fatigue,
weight loss,
hyperthermia,
dyspnea and cough .
CHEST X RAY ANALYSIS (fig.1)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: thick walled small cavity,
patchy area of consolidation and hyperdense nodules and micronodules
Left apex: large excavated consolidation area with probable intracavitary mass surrounded by nodules and micronodules
Right lung parenchyma: normal middle and lower areas
Left lung parenchyma: millimetric dense nodules in middle area
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.2)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: excavated mass,
bronchial wall thickening and branching dense micronodules in RUL.
Diffuse ground glass micronodules in RLL
Left lung parenchyma: excavated consolidation,
bronchial wall thinckening and branching dense micronodules in apico-posterior segment of LUL.
No definite intracavitary mass.
Diffuse ground glass micronodules in LLL
Mediastinum: calcified nodes
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT: Appearences are in keeping with active tuberculosis.
Diagnosis could be suggested from the chest XRay alone.
Once the major lesion is seen (LUL cavity in this case),
it is tempting not to assess more subtle changes such as left middle area nodules or right upper lobe smaller cavity.
"Satisfactory of search"* (SOS) frequently prevents the search for secondary or more subtle abnormalities.
Knowing that a CT scan will follow the XRay as soon as an abnormal finding is depicted shouldn't prevent a complete and systematic review of all areas.
*References : Coche E.,
Duyck P.
and al. Comparative CT and standard radiography of chest 2011 ,
Springers editions
CASE 2
REQUEST FORM : 36 year-old man presenting with chest pain and purulent expectorations .
CHEST X RAY ANALYSIS (fig.3 )
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm:normal
Left costophrenic angle: normal
Trachea:normal
Heart size:normal
Right apex: excavated area of consolidation with a fluid level.
Second smaller area of consolidation with possible excavation.
Left apex :normal
Right lung parenchyma: normal except for the right apex
Left lung parenchyma :normal
Upper abdomen : normal
Right thoracic wall:normal
Left thoracic wall:normal
CT SCAN ANALYSIS (fig.4):
Right lung volume:normal
Left lung volume:normal
Right lung parenchyma: sub-pleural excavated area of consolidation in the posterior segment of the RUL (fluid level) surrounded by ground-glass shadowing.
Localized area of pleural thickening in contact.
Further areas of ground-glassy and nodular areas of consolidation in the same territory.
Left lung parenchyma: normal
Mediastinum: pre-tracheal and right hilar lymphadenopathies
Heart and vessels: normal
Upper abdomen:normal
Right pleural effusion: no
Left pleural effusion:no
Right thoracic wall:normal
Left thoracic wall:normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT: an excavated lesion with a fluid level is an abscess and is most often of bacterial origin.
The patient improved on antibiotics therapy.
All excavated lesions in upper zones are not tuberculosis,
and when there are no branching nodules on CT scan,
TB is unlikely.
CASE 3
REQUEST FORM: 82 year-old man with a history of adenocarcinoma of the prostate presenting with diffuse pain and fatigue .
CHEST X RAY ANALYSIS (fig.5 )
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour:normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm :normal
Right costophrenic angle :normal
Left hemidiaphragm:normal
Left costophrenic angle: normal
Trachea: normal
Heart size: moderately enlarged
Right apex: diffuse increased density of the RUL and mass-like lesion in the sub-clavicular area
Left apex: normal
Right lung parenchyma: normal except for the RUL opacity
Left lung parenchyma: normal
Upper abdomen : normal
Right thoracic wall: disappreance of the normal posterior aspect of the third and 4th ribs
Left thoracic wall:normal
Other:nothing to report
CT SCAN ANALYSIS :(fig.
6)
Right lung volume:normal
Left lung volume: normal
Right lung parenchyma: normal
Left lung parenchyma: normal
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: first and second ribs enlargement,
heterogeneity and osteocondensation,
third and fourth ribs osteolysis
Left thoracic wall:multiple small areas of osteocondensation on the ribs
Other bony structures: widespread osteocondensation areas on vertebral bodies with partial collapses.
CONCLUSION AND TEACHING POINT :
Multiple bone metastasis secondary to prostate carcinoma.
An opacity projecting over the lung fields on chest X-Ray does not necessarily arise from the lung parenchyma: quickly checking that all the posterior arches of the ribs are present and intact is mandatory on every chest X-Ray reported.
CASE 4
REQUEST FORM:31 year-old man with a history of immunosuppression,
cough and purulent expectorations .
CHEST X RAY ANALYSIS (fig.
7)
Right lung volume: possible loss of volume of the right paracardiac area with a subtle right shift of the right heart border
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal.
Sternotomy wires.
Right apex: normal.
On note: accessory azygos fissure
Left apex: normal
Right lung parenchyma: probable "ring-like" lesions in the right paracardiac area
Left lung parenchyma: branching "tram-tracks" or "finger gloves" opacities in LLL
Upper abdomen : normal
Right thoracic wall:normal
Left thoracic wall:normal
CT SCAN ANALYSIS (fig.
8)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: diffuse cylindric and cystic bronchiectasis with mucus plugs and small peripheral areas of consolidation.
Left lung parenchyma: diffuse cylindric and cystic bronchiectasis with mucus plugs and small peripheral areas of consolidation.
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
Bronchiectasies may be difficult to spot on chest X-Ray and extensive lesions are frequently underdiagnosed.
Tram-track and ring lesions should be spotted when present,
and observation of bronchial wall in hilar regions,
where it is best demonstrated,
may help.
CASE 5
REQUEST FORM : 68 year-old man,
smoker,
presenting with an episode of cough and hyperthermia.
CHEST X RAY ANALYSIS (fig.
9)
Right lung volume: hyperinflated
Left lung volume: hyperinflated
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: well-circumscribed mass overlapping the right hilum.
The right hilar vessels appear normal trough the mass,
and the mass appears distinct from the ascending aorta.
Ancillary finding: diffuse bronchial wall thickening.
Left lung parenchyma: diffuse bronchial wall thickening and "dirty lungs" appearances
Upper abdomen:normal
Right thoracic wall:normal
Left thoracic wall:normal
CT SCAN ANALYSIS (fig.
10)
Right lung volume: hyperinflated
Left lung volume: hyperinflated
Right lung parenchyma: diffuse centrilobular emphysema,
bronchial wall thickening.
Well-circumscribed mass appended to the left posterior pleura,
of fluid density with a few peripheral calcifications.
Left lung parenchyma: diffuse centrilobular emphysema,
bronchial wall thickening and branching nodules in the LLL.
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
This patient had a bronchial infection and the right posterior mass was an incidental finding.
When a hilar mass overlaps hilar vessels which otherwise have a normal appearance,
it is likely that the mass is situated anteriorly or posteriorly to the vessels.
The cystic,
benign looking appearance of the mass suggested a possible bronchogenic cyst,
but the most important move in that case was to try and find old chest X-rays.
Hyperinflation of the lungs is diagnosed when more than the 7th anterior rib intersects the diaphragm on the mid-clavicular line or when there is flattening of the hemidiaphragms (secondary to obstructive airways disease).
CASE 6
REQUEST FORM: 88 year-old man suffering from chronic obstructive pulmonary disease,
presenting with dyspnoea and cough occurring after a fall complicated by ribs trauma .
CHEST X RAY ANALYSIS (fig.11 )
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: enlarged
Left hilum: normal
Right hemidiaphragm: slightly elevated
Right costophrenic angle: blunt
Left hemidiaphragm: normal
Left costophrenic angle : normal
Trachea: normal
Heart size: normal
Right apex:normal
Left apex :normal
Right lung parenchyma: possible hyperdensity below the level of the right hemi diaphragm
Left lung parenchyma: left retro-cardiac paravertebral hyperdensity
Upper abdomen: normal
Right thoracic wall: displaced fractures of the posterior arches of the 9th and 10th ribs
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.
12)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: collapse/consolidation of the RLL
Left lung parenchyma: collapse/consolidation of the LLL
Mediastinum: normal
Right pleural effusion: small
Left pleural effusion: small
Heart and vessels: normal
Upper abdomen: normal
Right thoracic wall: fractures of the posterior arches of the 9th and 10th right ribs (not seen on provided pictures)
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
The discrepancy between the CXR subtle changes and the extensive RLL and LLL collapses/consolidations on CT scan is striking and shows how difficult it can be to spot retrocardiac or sub diaphragmatic opacities on CXR.
These areas need to be scrutinized,
the heart density is supposed to be homogeneous as well as the sub-diaphragmatic areas.
Blurring of cardiac or diaphragmatic outlines may help but were not present in this case.
CASE 7
REQUEST FORM: 60 year-old man with a history of immunosuppression (rhumatoid arthritis),
presenting with sore throat,
cough and hyperthermia
CHEST X RAY ANALYSIS (fig.
13)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: blurring of the lower part of the right heart border
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: small focus of consolidation in the RM and/or RLL
Left lung parenchyma: plate-like consolidation in the LUL
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.
14)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: multiple areas of triangular or band-like consolidations with air bronchogram in the RLL
Left lung parenchyma: multiple areas of triangular or band-like consolidations with air bronchogram in the LUL
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
The areas of consolidation on CT are more numerous than expected from the CXR.
Blurring of cardiac or diaphragmatic contours is an accurate sign to reveal subtle areas of consolidation.
These changes were consistent with infectious changes,
but alternatively organizing pneumonia could also be suggested as band-like or discoid consolidation with air-bronchograms on CT scan are suggestive of the diagnosis (distinct from classical band-like atelectasis with no air-bronchogram).
A follow-up CT scan was planned after antibiotic treatment.
CASE 8
REQUEST FORM: A 70 year-old woman presented with left posterior chest pain,
non- productive cough and hyperthermia.
CHEST X RAY ANALYSIS (fig.
15)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: paracardiac hyperdensity of low density
Left cardiac contour: seems sharp despite adjacent left basal opacity
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle :blunt
Left hemidiaphragm: normal
Left costophrenic angle :normal
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: possible right paracardiac opacity
Left lung parenchyma: LLL well limited opacity
Upper abdomen: normal except for obesity
Right thoracic wall: normal,
except for large fatty tissue and breast superimposition
Left thoracic wall: normal,
except for massive fatty tissue and breast superimposition
Other: Large rounded retrocardiac opacity overlapping the lower dorsal spine
CT SCAN ANALYSIS (fig.16)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: normal.
On note: right paracardiac fat-pad
Left lung parenchyma: excavated consolidation in the lingula
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: hiatal hernia
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
In oversized patients large superimpositions of soft tissue might be confusing on CXR.
Following contours of mediastinal and diaphragmatic borders can be of great help.
Pericardal fat-pads may mimic consolidation or masses but are usually of low density.
In this case the right paracardiac opacity was due to a fat-pad.
The left opacity was due to an area of infectious pneumonia in the lingula which should have erased the left heart border.
However a layer of mediastinal fat outlined the cardiac shadowing separating it from the parenchymal opacity.
The excavation was not depicted on CXR.
For the retrocardiac rounded opacity,
a lateral view could have been helpful in proving the diagnosis of hiatal hernia even if it could be suggested from the frontal CXR appearences.
Hiatal hernia may also appear as gas-filled retrocardiac structures.
HH: hiatal hernia,
FP: fat pad.
CASE 9
REQUEST FORM: 48 year-old woman presenting with right chest pain and hyperthermia.
CHEST X RAY ANALYSIS (fig.17)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: erased
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: erased
Right costophrenic angle: blunting and large pleural effusion
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: right paratracheal and right hilar round masses
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: diffuse increased density of the RLL
Left lung parenchyma: normal
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.18)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: normal except for bronchial wall thickening in the RLL
Left lung parenchyma: normal
Mediastinum: multiple hilar and paratracheal necrotic lymphadenopathies
Heart and vessels: normal
Right pleural effusion: moderate (but right pleural effusion partially drained after the CXR just before the CT scan)
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
Right pleural effusion and mediastinal necrotic lymphadenopathies secondary to small-cell carcinoma.
Falling in the trick of SOS (satisfaction of search) is possible in front of a large pleural effusion on a CXR,
but complete review of CXR is obviously necessary searching for the aetiology of the pleural effusion,
in this case mediastinal and tracheal outlines revealed the nodal masses.
CASE 10
REQUEST FORM : 62 year-old man presenting with worsening of chronic cough and dyspnea without chest pain or hyperthermia.
CHEST X RAY ANALYSIS (fig.19)
Right lung volume: overinflated
Left lung volume: overinflated
Right cardiac contour: normal
Left cardiac contour: enlarged main pulmonary artery
Right hilum: enlarged
Left hilum: normal
Right hemidiaphragm: flattened
Right costophrenic angle: blunt
Left hemidiaphragm: flattened
Left costophrenic angle: blunt
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: normal
Left lung parenchyma: normal
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.20)
Right lung volume: hyperinflated
Left lung volume: hyperinflated
Right lung parenchyma: diffuse centrilobular emphysema and bronchial wall thickening
Left lung parenchyma: diffuse centrilobular emphysema and bronchial wall thickening
Mediastinum: normal
Heart and vessels : enlarged main pulmonary artery (36mm)
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT :
Emphysema,
chronic obstructive airway disease and secondary pulmonary hypertension (pulmonary artery > 31mm) secondary to tobaccco smoking.
Typical features of fibro-emphysema on CXR: more than 7 anterior ribs visible above the diaphragm and marked flattening of both hemidiaphragms.
The enlarged right hilum on CXR was vascular (right pulmonary artery dilatation) as suggested by the 'hilar convergence sign': pulmonary vessels can be seen to converge and join a dilated right pulmonary artery.
CASE 11
REQUEST FORM: 56 year-old woman presenting with suspicion of ovarian adenocarcinoma and hyperthermia.
CHEST X RAY ANALYSIS (fig.21 )
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal (but there is a right paracardiac hyperdensity separated from the right heart border)
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: blunt
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: right para-cardiac hyperdensity
Left lung parenchyma: normal
Upper abdomen: sub-diaphragmatic air crescent
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.
22)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: RLL consolidation
Left lung parenchyma: normal
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: pneumoperitoneum
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT: RLL pneumonia and pneumoperitoneum secondary to surgical resection of an ovarian tumour.
On CXR,
the "silhouette sign" indicates that the right lobe consolidation was sitting in the RLL (conservation of a normal right heart border): This sign is useful in localising areas of airspace opacities,
atelectasis or mass within the lung.
The loss of the normal following outlines indicates lesions sitting in:
-right heart border: ML or medial part of the RLL
-right hemi-diaphragm: RLL
-aortic knuckle: lLUL
-left heart border: lingula segments of the LUL
-left hemi-diaphragm or descending aorta: LLL
CASE 12
REQUEST FORM: 65 year-old man with a long history of hypertrophic cardiomyopathy,
presenting with dyspnoea at rest,
atypical chest pain and bloody sputum .
CHEST X RAY ANALYSIS (fig.23)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: hypertrophy
Left hilum: normal
Right hemidiaphragm: blurring of the middle part
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size : cardiomegaly
Right apex: normal
Left apex: normal
Right lung parenchyma: subtle increased density above the right hemidiaphragm
Left lung parenchyma: normal
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.24)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: ground glass shadowing in the RLL and the middle lobe and thickening of the interlobular septae
Left lung parenchyma: diffuse ground glass shadowing in the LLL and thickening of the interlobular septae
Mediastinum: normal
Heart and vessels: left cardiac chambers enlargement (not seen on chosen images)
Right pleural effusion: moderate
Left pleural effusion: moderate
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT: Left cardiac failure and acute pulmonary oedema.
Striking differences in the severity of the lesions on CXR and CTscan performed only a couple of hours later.
The hint on CXR is given by the loss of the right hemidiaphragm sharpness in its middle portion.
The pleural effusion in unsuspected on the CXR,
as the costophrenic angles remain sharp.
CASE 13
REQUEST FORM: 65 year-old man,
alcoholic,
presenting with recent weight-loss and dysphagia.
CHEST X RAY ANALYSIS (fig.25)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: erased by a left paracardiac opacity
Right hilum: elevated
Left hilum: no seen
Right hemidiaphragm: normal
Right costophrenic angle: not covered by XRay
Left hemidiaphragm: erased
Left costophrenic angle: not covered by XRay
Trachea: deviated towards the right
Heart size: normal
Right apex: increased density
Left apex: increased density
Right lung parenchyma: RUL opacity with possible cavities.
Probable LUL atelectasis given the elevation of the right hilum and the right paratracheal opacity.
Increased density in the RLL
Left lung parenchyma: large excavated consolidation in the LUL.
Increased density in the lingula and LLL (silhouette signs) in keeping with further areas of consolidation.
Upper abdomen: normal
Right thoracic wall:normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.26)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: large excavated consolidation area in RUL.
Patchy posterobasal infiltrates with branching nodules.
Left lung parenchyma: large excavated consolidation area in LUL.
Ground glass and consolidation areas in the lingula. Patchy posterobasal infiltrates with branching nodules
Mediastinum: paratracheal and pretracheal lymphadenopathies
Heart and vessels: normal
Right pleural effusion: moderate
Left pleural effusion: moderate
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bony structures: normal
CONCLUSION AND TEACHING POINT: bilateral excavated areas of consolidation in keeping with a mycobacterial infection but given the alcoholic history,
semi-invasive fungal infections such as aspergillosis are also in the differential diagnosis list.
Bilateral postero-basal changes including consolidation areas and branching nodules raise the possibility of gastric content aspiration,
frequent in those patients.
CASE 14
REQUEST FORM :79 year-old man presenting with decompensated heart failure and weight loss .
CHEST X RAY ANALYSIS (fig.27)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: erased
Right hilum: not seen
Left hilum: not seen
Right hemidiaphragm: normal
Right costophrenic angle: blunt
Left hemidiaphragm: erased
Left costophrenic angle: not seen due to left basal complete opacity and pleural effusion
Trachea: deviated towards the right
Heart size: probably enlarged
Right apex: normal
Left apex: normal
Right lung parenchyma: RUL ground glass shadowing sitting oon the horizontal fissure.
Left lung parenchyma: large pleural effusion overlapping a possible area of consolidation in the left middle area
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.28)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: diffuse ground glass shadowing in the RUL on a background of centrilobular emphysema
Left lung parenchyma: LLL collapse and consolidation,
ground glass shadowing in the lingula,
a few areas of interlobular septal thickening (not shown on figures)
Mediastinum: normal
Heart and vessels: left heart chambers enlargement
Right pleural effusion: small
Left pleural effusion: large effusion shifting the mediastinum to the right
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
CONCLUSION AND TEACHING POINT : Cardiogenic pulmonary oedema on a background of diffuse emphysema.
Ground glass shadowing and areas of consolidation have an unusual "sponge-like" appearance when occuring on emphysematous lungs.
CASE 15
REQUEST FORM : 61 year-old man presenting for a bad fall on the left side.
Left hemithorax and left flank pain.
CHEST X RAY ANALYSIS (fig.29)
Right lung volume: normal
Left lung volume: decreased
Right cardiac contour: not visible
Left cardiac contour: not visible
Right hilum: enlarged right pulmonary artery
Left hilum: not seen
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: not seen
Left costophrenic angle: not seen
Trachea: shifted to the left
Heart size: not assessable
Right apex: normal
Left apex: complete opacity
Right lung parenchyma: trans-mediastinal herniation towards the left side
Left lung parenchyma: diffuse increased density with possible persisting aerated lung at the left base
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall:deformity of the thoracic wall with narrowed intercostal spaces and abnormal angle of inclination of the left ribs.
CT SCAN ANALYSIS (fig.30)
Right lung volume: normal but herniated towards the left side
Left lung volume: complete agenesis of the left lung
Right lung parenchyma: normal
Left lung parenchyma : non assessable
Mediastinum: leftward deviation
Heart and vessels: leftward deviation
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: no ribs agenesis
Other bones structures: normal
CONCLUSION AND TEACHING POINT: Left lung agenesis.
Any disease which causes volume loss in one hemithorax will attract the trachea and mediastinum towards this side.
Lung herniation might also happen,
more frequently from right to left,
and may be secondary to collapse of a lung or a lobe,
lobectomy or pneumonectomy,
as well as congenital abnormalities.
PS: in post-traumatic evaluation,
stalk down any sign of rib fractures and pneumothorax in particular at the apices.
CASE 16
REQUEST FORM :77 year-old woman presenting with productive cough and bronchial irritation.
CHEST X RAY ANALYSIS (fig.31 )
Right lung volume: normal
Left lung volume: volume loss of the LLL
Right cardiac contour: focal blurring
Left cardiac contour: blurring
Right hilum: not well seen
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: blunt and lower lateral pleura thickening
Trachea: normal
Heart size: moderately enlarged
Right apex: normal
Left apex: normal
Right lung parenchyma: loss of the normal transparency of the RLL.
Small area of air-space shadowing in the RUL.
Thickening of the horizontal fissure and band-like consolidation in the same area.
Air-space shadowing in the ML (silhouette sign with right heart border).
Possible ring shadows in the ML.
Left lung parenchyma: loss of transparency of the left base,
small elevation of the left hemidiaphragm,
nodules in the left middle area.
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall:normal
CT SCAN ANALYSIS (fig.32 )
Right lung volume: normal
Left lung volume: lingular atelectasis
Right lung parenchyma: patchy areas of consolidation surrounding tubular bronchiectasis in ML with areas of mucus plugging.
Thickening of the horizontal fissure.
Left lung parenchyma: lingular bronchiectasis with areas of collapse/consolidation.
Bronching nodules in the LLL
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
CONCLUSION AND TEACHING POINT: patchy areas of consolidation and bronchiectasis in the ML and lingula in keeping with supra-added infection.
The slightly elevated left hemidiaphragm suggests they might be some area of atelectasis in the left lung (usually the left hemidiaphragm lies below the right hemidiaphragm by approximately 2 cm)
CASE 17
REQUEST FORM: 53 year-old woman presenting with lumbar pain.
History of large uterin fibroms.
CHEST X RAY ANALYSIS (fig.33 )
Right lung volume: normal
Left lung volume: reduced
Right cardiac contour: normal
Left cardiac contour:erased
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: blunt
Left hemidiaphragm: normal
Left costophrenic angle: not seen and left pleural effusion
Trachea: normal
Heart size: normal
Right apex: nodular opacities
Left apex: pleural thickening
Right lung parenchyma: nodules of different size are visible associated with a small pleural effusion.
Left lung parenchyma: increased density of the left lung,
irregular lobulated and circumferential pleural thickening,
several nodules of different size ,
retrocardiac area of consolidation
Upper abdomen : normal
Right thoracic wall:
Left thoracic wall:normal
CT SCAN ANALYSIS (fig.34 )
Right lung volume: normal
Left lung volume: reduced
Right lung parenchyma: multiple and disseminated nodular lesions
Right pleural effusion: small
Left lung parenchyma: multiple and disseminated nodular lesions.
Left pleural effusion: necrotic heterogenous partially enhanced thickened lobulated pleura
Mediastinum: normal
Heart and vessels: normal
Upper abdomen: hypodense nodular lesion of the liver parenchyma
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
CONCLUSION AND TEACHING POINT: Pleural and parenchymal metastatic extension of a uterine leiomyosarcoma.
Soft tissue thickening of the pleura is best seen after contrast injection at a late portal phase,
therefore when there is a pleural effusion,
it is often helpful to rescan the base of the lungs before the abdominal acquisition.
Tumoral pleura is most frequently due to mesothelioma or adenocarcinoma,
but lymphoma and metastatic sarcomas are also in the differential diagnosis.
CASE 18
REQUEST FORM: A 54 year-old man presented with epigastric pain and diarrhea.
After gastric endoscopy,
CXR was performed for hyperthermia and shivers .
CHEST X RAY ANALYSIS (fig.
35)
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Right lung parenchyma: large homogenous oval opacity,
well-limited projecting over the lower part of the RUL .
No calcifications are seen inside or on the periphery of the lesion
Left lung parenchyma: normal
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.
36)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: antero-apical oval mass with smooth borders surrounded by normal lung tissue and a small pleural tag.
The content is homogenous with a fluid density.
Left lung parenchyma: normal
Mediastinum: normal
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion:no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
Other : large cystic lesion in the right lobe of the liver.
CONCLUSION AND TEACHING POINT: Pulmonary and hepatic hydatid cysts. Purely cystic large parenchymal lesions are infrequent in the lungs and hydatic cyst is one of the principal etiologies.
Recent travelling of the patient in sub-saharan continent,
and the association with a cystic liver lesions can be diagnostic clues.
CASE 19
REQUEST FORM : A 85 year -old man presented with dyspnoea
CHEST X RAY ANALYSIS (fig.
37 )
Right lung volume: normal
Left lung volume: normal
Right cardiac contour: normal
Left cardiac contour: normal
Right hilum: normal
Left hilum: normal
Right hemidiaphragm: normal
Right costophrenic angle: blunt
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: large areas of calcifications
Left apex: normal
Right lung parenchyma: large irregular opacities,
most of them of calcium density projected over upper and middle part of the right lung
Left lung parenchyma: normal
Upper abdomen: normal
Right thoracic wall:normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.
38)
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: centrolobular emphysema predominant at pulmonary apex associated with calcified pleural plaques in the upper and middle regions.
No pulmonary consolidation visible
Left lung parenchyma: centrolobular emphysema predominant at pulmonary apex .
No pulmonary consolidation visible
Mediastinum: calcified lymph nodes.
Heart and vessels: normal
Right pleural effusion: no
Left pleural effusion:no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
CONCLUSION AND TEACHING POINT: Unilateral Calcified pleural plaques related to an old tuberculous pleuresis.
The difference with asbestos-related pleural plaques is that the later are usually bilateral and lie below the level of the carina.
CASE 20
REQUEST FORM: 65 year-old man presenting with a few episodes of haemoptysis over the past 3 months and a long history of smoking.
CHEST X RAY ANALYSIS (fig.
39)
Right lung volume: small (sub-optimal inspiration)
Left lung volume: small (sub-optimal inspiration)
Right cardiac contour: lobulated
Left cardiac contour: erased
Right hilum: not seen
Left hilum: enlarged
Right hemidiaphragm: normal
Right costophrenic angle: normal
Left hemidiaphragm: normal
Left costophrenic angle: normal
Trachea: normal
Heart size: normal
Right apex: normal
Left apex: normal
Mediastinum: enlarged upper mediastinum
Right lung parenchyma: normal
Left lung parenchyma: increased density of the left lung and triangular consolidation in the left para-hilar region.
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
CT SCAN ANALYSIS (fig.40 )
Right lung volume: normal
Left lung volume: normal
Right lung parenchyma: necrotic mass in the right costo-vertebral angle.
Ground-glass shadowing in the ML and the RLL.
Left lung parenchyma: Lingular consolidation/atelectasis.
Mediastinum: necrotic mass located on the anterior part of mediastinum and in the left paracardiac area,
narrowing the left main bronchus.
Heart and vessels: extension of the mass in the left pulmonary artery
Right pleural effusion: no
Left pleural effusion: no
Upper abdomen: normal
Right thoracic wall: normal
Left thoracic wall: normal
Other bones structures: normal
CONCLUSION AND TEACHING POINT: Small cell lung cancer with anterior mediastinal and left pulmonary artery extension.
The ground-glass areas of attenuation are probably secondary to haemoptysis and alveolar blood-filling.