Chilaiditi Sign On Chest X ray

The X ray shown below is of an asymptomatic person. 

Description Of Chilaiditi Sign
Chilaiditi described this normal variant in 1911 where the transverse colon is interposed between the right hemidiaphragm and the liver.
Its prevalence is thought to be 0.025%.

Occasional reports describe patients with Chilaiditi’s syndrome where patients complain of intermittent abdominal pain requiring laparotomy to rule out other causes of peritonism, e.g. perforated ulcer, ruptured appendix.

Pulmonary Alveolar Microlithiasis - Chest X Ray

A 39 years old female came to radiology department for X-ray chest with history of dyspnea on exertion. The X ray is shown as below:

Radiological Findings on the X ray Chest: X-ray chest (in the picture above) shows that the lung fields are diffusely occupied by discrete high density opacities resembling grains of sands. In spite of
superimposition or summations of shadows the individual deposits are identifiable and measure about a 1 mm in diameter thick and streaky. The opacity appears confluent showing the lungs as almost white with obliteration of the mediastinal and diaphragmatic contours and pulmonary vascular marking are indistinct. The density is greater over the lower than the upper zone.

Comments and Explanation: The characteristic finding on the chest radiograph is that of a fine, dense stippling. This is a well-defined, nodular infiltrate which involves both lungs, and may be so extensive as to cause opaque lungs with relative lucency of the mediastinal structures, diaphragm and pleura. There is widespread parenchymal calcification.
In addition to the finding seen, other findings that may be seen include bullae in the lung apices, a zone of increased lucency between lung parenchyma and the ribs (a black pleural line) and pleural calcification.
In some patients concentration of the nodules in subpleural, para septal and peribronchiolar alveoli can produce linear strands of calcification parallel to or perpendicular to the pleural surface.

Foreign Body Seen on X ray

A 65-year-old male presented with cardiogenic shock. He had an emergency CABG (Coronary artery bypass grafting) which was associated with a very stormy peri-operative period.  His CXR (shown in picture below) was taken upon arrival at the Intensive Care Unit (ICU).

What is the most significant abnormality?

Case Discussion:

The CXR shows an opaque density in the region of the right lower zone.
Each lung field on an erect CXR is divided into three zones.

1. The upper zone is an area which lies above a horizontal line drawn from the medial end of the second rib anteriorly. 
2. The middle zone lies below this and is bordered inferiorly by a line drawn similarly from the fourth rib. 
3. The lower zone lies below this. 

This opaque density is similar in configuration to a tooth which was dislodged during emergency
intubation of this patient.

See the X ray again with the arrow pointing to the opacity

Meconium Aspiration Syndrome - X ray Chest

This X ray is of a one day old baby who had difficulty breathing.

X-ray chest shows right upper lobe consolidation and rest of the lungs show patchy to streaky areas suggesting meconium aspiration syndrome

Explanation: In meconium aspiration syndrome (MAS) the newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery.
Meconium is the early feces passed by a newborn soon after birth, in some cases; the baby passes meconium while still inside the uterus. This usually happens due to lack of enough blood and oxygen.
Once the meconium has passed into the amniotic fluid, the baby may breathe meconium into the lungs. This condition is called MAS. It causes breathing difficulty due to inflammation in the lungs after birth.
Meconium aspiration syndrome is a leading cause of severe illness and death in newborns. However, in most cases, the outlook is excellent and there are no long-term health effects provided the infant is placed in newborn intensive care unit for close observation and treatment

Congestive Cardiac Failure As Seen On Chest X ray

An elderly male presents with a history of exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

His chest x ray is shown below:

Diagnosis : Congestive cardiac failure

Discussion: The Chest X Ray shows classic evidence of left ventricular failure, i.e.

• cardiomegaly (cardiothoracic ratio >50%), 
• upper lobe pulmonary venous diversion, and 
• Kerley B lines (which indicate distension of lymphatics). 

In addition, there is evidence of sternotomy wires, suggesting previous coronary artery bypass surgery (CABG).

Followup Of this Patient: Following diuresis, the pulmonary infiltrates have cleared . (X ray shown below).

A 60 year old man presents with cough not responding to antibiotics...

The x ray shown in the picture above is of a 60 year old man who presented with a history of cough that was not responding to antibiotics and cough syrups.

X Ray Description: X-ray chest shows a mass lesion measuring 6 cm in diameter in left lower zone of which the margins are not smooth, finding suggestive of carcinoma lung, however, needs confirmation on CT chest.

Case Follow Up : The patient was subjected to CT chest (see the picture below) shows moderately
enhancing irregular mass lesion measuring 5 × 6 cm in the superior segment of Left lower lobe and lingula. Feeding vessel is also seen. Multiple areas of necrosis are seen within. There is central cavitation and air fluid level. Surrounding lung shows infiltration. Multiple pretracheal, carinal, and subcarinal lymph nodes are seen measuring 11–17 mm.

Ruptured Liver Abscess.

A 50-year-old male presented to the Emergency Room with shock and a four-day history of a febrile illness. He required intubation and was started on inotropes.
His Chest X ray is shown below:

Case Discussion: It is important to look at the “blind areas” of the Chest X ray in order not to miss important clues. These areas are under the diaphragm, behind the heart, the hilum, and the soft tissues. This Chest X ray shows a lucency over the liver density. The lucency does not conform to the usual bowel configuration. In this clinical context, an important differential diagnosis to be considered is a ruptured liver abscess. This can be confirmed either by bedside ultrasound or CT,

A CT scan was done in this patient which is shown below:

A 2 year old child with Bronchopneumonia

A 2 years old child was brought to radiology department for X-ray chest with cough and high fever over last 3 days. His X ray is shown below:

X-ray chest shows soft small ill-defined opacities scattered in both lung fields partially sparing the lower zones.

Comments And Explanation
On X-ray bronchopneumonia appears as small fluffy ill-defined acinar nodules, which coalesce and enlarge with time and may develop into segmental and lobar densities with volume loss from airway obstruction secondary to mucus plugging and bronchial narrowing.

Diagnosis: Bronchopneumonia.

Clinical Discussion
Bronchopneumonia is a combination of interstitial and alveolar disease.
In bronchopneumonia the insult begins in airways, involves bronchovascular bundle and trickles into alveoli, which may develop and contain edema fluid, blood, leukocytes, hyaline membranes and organisms.

Primary Spontaneous Pneumothorax - Chest X ray

This X ray is of a 25 year old male patient who presented with sudden onset of left sided chest pain.

X ray Description: The CXR shows the visceral pleura separated from the parietal pleura by air which now occupies the potential space in the pleural cavity. The visceral pleura must not be mistaken for skin-fold shadows which usually occur in supine or obese patient CXR. In addition, the line from skin folds can be seen to cross the chest wall.

A 70 years old male patient with a long history of cough and general weakness.

A 70 years old male patient with a long history of cough and general weakness. His Chest X ray is shown in the picture below:

X-ray chest shows a mass lesion in right upper lobe (arrow), likely a bronchogenic carcinoma.

To confirm the diagnosis, CT chest was performed. CT chest (shown in the picture below A&B) shows ill-defined rounded opacity abutting the chest wall with radiating strand seen in right upper lobe with minimal necrosis within, seen in mediastinal window.

Interpreting Chest X ray Of A Patient Diagnosed With Pneumonia

A 35-year-old male presented with fever, cough, and purulent sputum for one week. His Chest X ray is shown below: 

The CXR shows a focal shadow in the right lower lobe with air bronchograms suggestive of pneumonia. It is clearly in the right lower lobe because the right hemidiaphragm is effaced. Right middle lobe shadows would efface the right heart border.
The presence of air bronchograms indicates pathology in the alveoli, as the conducting airways remain patent with air.
Water or blood can also occupy the alveoli as a result of pulmonary edema or pulmonary hemorrhage respectively. There should be other supporting signs such as cardiomegaly, upper lobe diversion, and
Kerley B lines with pulmonary edema.

The differential diagnoses of a focal shadow with air bronchograms include 

• bronchoalveolar cell carcinoma and 
• lymphoma. 

Developing Aspergilloma - As Seen On Chest X ray

A 43 years old male presented with a history of cough, fever and weight loss with loss of appetite since two months. His Chest X ray is shown below:

X-ray chest shows a right mid zone cavity with thick irregular wall with non-homogeneous shadowing due to an irregular sponge work filling the cavity with intervening air spaces.

Comments And Explanation:
Superinfection with Aspergillus generally occurs in a pre-existing cavity (tuberculous or bronchiectasis) in immune-compromised patient.
Initially, the aspergilloma appears as an irregular spongework filling the cavity with intervening air spaces (as seen in the above X ray). Presumably this appearance reflects the presence of irregular fonds of fungal mycelia mixed with residual intracavity air. Furthermore, thickening of the wall of the cavity can be a finding of superimposed fungal infection well prior to development of a fungal ball as has been demonstrated in this case.

A 45 years old patient presents with history of cough and expectoration for several months....

A 45 years old patient presents with history of cough and expectoration for several months. His chest X ray is shown below:

Describe the findings on the X ray and what could be the diagnosis?

Radiological Findings And Explanation
X-ray chest shows that the lungs are large in volume with streaky shadows and multiple cystic lesions with air fluid levels. These cystic lesions can also be seen through the heart shadow. This is most probably a case of bronchiectasis.

A Newborn Baby with Difficulty Breathing since Birth

X ray of a newborn baby with difficulty breathing since birth is shown below:

Radiological Findings:  X-ray chest  shows opaque left hemithorax and the entire mediastinum is pulled to the left, the right lung has herniated beyond the midline. The endotracheal tube and Ryles tube are in situ. 

Diagnosis suggested is complete agenesis of left lung. This can be confirmed on CT chest.

Comments: 

The findings seen on chest film are absence of lung, opaque hemithorax, mediastinal shift with hernia of contralateral lung to the affected side with normal and symmetrical bony thorax.

CT chest can be helpful to differentiate the three categories of agenesis

(a) complete agenesis, 

(b) lung aplasia and 

(c) lung hypoplasia.

Lung agenesis is rare, developmental anomaly of the lung. It can be:

1. Complete agenesis, manifested by total agenesis of lung tissue, bronchus and pulmonary vessels.

2. Lung aplasia manifested by a rudimentary bronchus but absent lung tissue and pulmonary vessels.

3. Lung hypoplasia manifested by rudimentary bronchus with hypoplastic lung tissue and pulmonary vessels.

Post-traumatic Pneumothorax.

A 24 years old male was brought to radiology department for X-ray chest following a road traffic accident. The X ray is shown below:

Radiological Findings: Chest X-ray shows presence of the air within the right pleural cavity with volume loss of right lung, as a result the right lung has partially collapsed. The outline of collapsed lung is seen well against the air.

Diagnosis: Post-traumatic Pneumothorax.

Clinical Discussion: Presence of the air within the pleural cavity is termed as the pneumothorax.
Air enters into the pleural cavity through the defect in pleural layers either spontaneously or due to trauma.

Pleural Calcification On Chest X ray

A 45 years male patient came to radiology department for X-ray chest with history of cough and expectoration of several months duration.

The X ray is shown below:

Chest X-ray (in the above picture) shows a large plaque of calcification covering the lateral and anterior part of left lung. There is crowding of overlying ribs.
Calcified pleural plaques have a characteristic rolled edge along its margin
Left upper lobe shows fibrotic lesions with bronchiectatic change and calcific spots are also seen.

Explanation:
Magnified view (shown below) shows that pleural calcification plaques have a characteristic rolled edge along its margin. (marked by arrows)

In general, pleural calcification is sequelae of hemothorax, empyema, tuberculosis or asbestos exposure.

Pleuropulmonary Tuberculosis - Chest X-Ray

A 45 years old male came to radiology department for X-ray chest with history of cough, mild fever and weight loss. The x ray is shown below:

X-ray chest shows fibro infiltrative lesions in right upper zone with areas of early calcification and moderate pleural effusion on left sidewith minimal tracheal pull to right side.

Comments And Explanation: Pleural effusion is the accumulation of fluid in the pleural space, i.e.
between the visceral and parietal layers of pleura. The fluid may be transude, exudate, blood, chyle or rarely bile.
Pleural fluid casts a shadow of the density of water on the chest radiograph. The most dependent recess of the pleura is the posterior costophrenic angle. A small effusion will, therefore, tend to collect posteriorly, however, a lateral decubitus view is the most sensitive film to detect small quantity of free pleural effusion (as small as 50 ml). 100–200 ml of pleural fluid is required to be seen above the dome of the diaphragm on frontal chest radiograph. As more fluid is accumulated, a
homogeneous opacity spreads upwards, obscuring the lung base.
Typically this opacity has a fairly well-defined, concave upper edge (as seen in picture above), which
is higher laterally and obscures the diaphragmatic shadow. Frequently the fluid will track into the pleural fissures.
A massive effusion may cause complete radiopacity of a hemithorax. The underlying lung will retract
towards its hilum, and the space occupying effect of the effusion will push the mediastinum towards the opposite side.
USG chest confirms the presence or absence of the pleural fluid; it also shows the septations within the pleural fluid with or without solid component within the lesion. USG helps in guiding aspiration of pleural fluid.
CT scan is the most sensitive modality for detection of presence of minimal fluid. It allows distinction between free and loculated fluid showing its extent and localization.

Pseudotumor Of The Lung On Chest X ray

X ray chest of a 48 year old woman who presented with generalized weakness is shown below:

Description: Chest X-ray shows an oval soft tissue density which overlays over most of the minor fissure. It is well-defined, no calcification seen and the surrounding lung is clear.

Diagnosed as Pseudotumor.

Comments And Explanation: Loculation within the fissure gives appearance of a tumor and is referred as pseudotumor. The pulmonary pseudotumor is sharply marginated collection of pleural fluid contained either within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure. Pseudotumors are identified on chest X-rays on their lenticular pattern.
CT chest confirms a loculated effusion within the fissure with Hounsfield value that of a transudate. The pseudotumor resolves with conservative management.
Most occur in the minor (horizontal) fissure and are seen on both the frontal and lateral radiograph; those that occur in the oblique or major fissure may only be seen on the lateral view. Pseudotumors may be erroneously diagnosed as parenchymal lung nodules or masses.

Clinical Discussion: Pseudotumor or vanishing tumor of the lung is an appropriate designation for a

A Case Of Encysted Pleural Effusion

A 26 years male came to radiology department for X-ray chest with history of cough and fever.
The X -Ray is shown below:

Radiological Findings On X-Ray Examination:
X-ray chest (in the picture above) shows encysted pleural effusion (arrow) along left lateral chest wall, i.e. costoparietal in position, and on right side there is free pleural effusion (twin arrow).

Comments And Explanation: 
The chest radiographic appearance depends on the site of the loculus, the amount of fluid and the radiographic projection. When seen en face it usually appears as an oval opacity, its margin partially well-defined and partially ill defined. When viewed tangentially, it is sharply defined on its convex pulmonary aspect. In moderate and massive effusion there is significant shift of the trachea and the apex of the heart to the opposite side. In the case of encysted effusions the inner margins may be more convex and the mediastinal shift minimal. If the encystment occurs in the interlobar regions there may be formation of rounded or oval opacities which may resemble a tumor.

Pleural effusion On Chest X ray

A 28 years old male came to radiology department for X-ray chest with history of breathlessness on exertion since 10 days.

X-ray chest  shows a large pleural effusion on left side, the trachea and mediastinum are pushed to the right, right lung field is clear.

Pleural effusion is the accumulation of fluid in the pleural space, i.e. between the visceral and parietal layers of pleura.
The fluid may be transude, exudate, blood, chyle or rarely bile.
Pleural fluid casts a shadow of the density of water on the chest radiograph. The most dependent recess of the pleura is the posterior costophrenic angle. A small effusion will, therefore, tend to collect posteriorly; however, a lateral decubitus view is the most sensitive film to detect small quantity of free pleural effusion (as small as 50 ml). 100–200 ml of pleural fluid is required to be seen above the dome of the diaphragm on frontal chest radiograph. As more fluid is accumulated, a homogeneous opacity spreads upwards, obscuring the lung base. Typically this opacity has a fairly well-defined, concave upper edge , which is higher laterally and obscures the diaphragmatic shadow. Frequently the fluid will track into the pleural fissures.
A massive effusion may cause complete radiopacity of a hemithorax. The underlying lung will retract
towards its hilum, and the space occupying effect of the effusion will push the mediastinum towards the opposite side.