Test

Question 1

CLINICAL HISTORY:
32yo Female
Dyspnoea

Answer 1

FINDINGS:
Bilateral reticulonodular shadowing with diffuse cystic changes.
Lung volumes are preserved.
No pleural abnormalities demonstrated.

Heart size is normal.
Hila and mediastinal contours are normal.

IMPRESSION:
Lymphangioleiomyomatosis

• BACKGROUND INFORMATION:*
• Almost exclusively present in females*
• May present with spontaneous pneumothorax*
• Can be associated with chylothorax*
• May be independent or part of a greater tuberous sclerosis complex*
• Can be associated with abdominal angiomyolipomas.*

DIFFERENTIAL DIAGNOSIS:
Langerhans Cell Histiocytosis (Usually has a smoking history and present in an older age group)
Overlapping emphysematous and granulomatous disease

FOLLOW UP:
Correlation with smoking history
HRCT
Respiratory referral
Bronchial biopsy / lavage
Serum ACE to r/o sarcoidosis
Genetic testing for TSC
U/S abdomen for AMLs

Question 2

CLINICAL HISTORY:
75yo Male
Right shoulder pain and paraesthesia

Answer 2

FINDINGS:
A large mass is visualised at the right lung apex.
The left lung is clear.
No pleural abnormality is demonstrated.

Skeletal review is unremarkable, no evidence of rib destruction associated with the mass.
Heart size is normal.

IMPRESSION:

Right apical mass in keeping with Pancoast tumour.

BACKGROUND INFORMATION:

Primary bronchogenic malignancy which presents in the lung apex and invades the surrounding soft tissues. This may result in Pancoast syndrome (malignant invasion of the brachial plexus) in roughly 25% of patients.

DIFFERENTIAL DIAGNOSIS:

• Pulmonary metastasis
• Primary pleural malignancy i.e. mesothelioma
• Chest wall tumour i.e. Ewing’s Sarcoma or PNET
• Pleuro-parenchymal fibrosis i.e. from previous Tuberculosis

FOLLOW UP:

• Respiratory referral
• CT CAP for staging
• Consideration of MRI if neurological symptoms
• Consideration of biopsy

Question 3

CLINICAL HISTORY:

62yo Male

Pyrexia and cough, ?HAP

Answer 3

FINDINGS:

Extensive airspace shadowing in the right upper lobe with inferior bulging of the transverse fissure. There is evidence of internal cavitation. The left lung is clear.

Small right sided pleural effusion.

Heart size is normal. Normal hilar appearances, no evidence of lymphadenopathy. Mediastinal contours are normal.

IMPRESSION:

Cavitating right upper lobe pneumonia, presence of bulging transverse fissure could suggest Klebsiella as a causative organism.

BACKGROUND INFORMATION:

Klebsiella pneumonia occurs from infection with the klebsiella pneumoniae organism. It is a common gram-negative respiratory infection. If cavitation occurs it happens early in the disease process and progresses quickly. Cavitation is much more common than in pneumococcal infections.

DIFFERENTIAL DIAGNOSIS:

• Mycobacterial infection i.e. Primary Tuberculosis (cavitation comparatively uncommon and usually presents with ipsilateral hilar lymphadenopathy)
• Other necrotising lobar pneumonias

FOLLOW UP:

• Sputum culture to determine organism
• Respiratory referral +/- CT

Question 4

CLINICAL HISTORY:

New cough, ?NG tube position

Answer 4

FINDINGS:

Multiple dense radiopacities demonstrated in both lung bases suggesting aspiration of barium sulphate, I note that a barium swallow was performed yesterday.

Lungs are otherwise clear, no pleural abnormalities.

NG tube is correctly sited, safe for use.

Heart size is normal, hila and mediastinal contours are normal.

IMPRESSION:

Aspiration of barium sulphate

BACKGROUND:

Some patients may aspirate on barium sulphate during GI radiological investigations. If a patient is pre-determined as an aspiration risk then a non-ionic iodinated contrast study is usually performed.

DIFFERENTIAL DIAGNOSIS:

None

FOLLOW UP:

If new aspiration (as in this scenario) patient would benefit from chest physiotherapy assessment

Question 5

CLINICAL HISTORY:

Worsening SOB

Weight loss

Answer 5

FINDINGS:

Prominent pleural shadowing throughout the right hemithorax. The left lung and pleura are clear.

Heart size is normal, hila and mediastinal contours are normal.

IMPRESSION:

Appearances are concerning for mesothelioma.

BACKGROUND:

Uncommon primary malignacy which is pleural in the vast majority of cases. It has a strong association with occupational asbestos exposure (predominantly crocidolite).

DIFFERENTIAL DIAGNOSIS:

• Loculated pleural effusion i.e empyema
• Pleural metastases
• Pleural plaques

FOLLOW UP:

• Respiratory referral, assuming appearances are not already known
• Pleural phase CT CAP

Question 6

CLINICAL HISTORY:

76yo Male

Longstanding cough

Answer 6

FINDINGS:

Bilateral reticular interstitial shadowing with a lower zone predominance. Large calcified pleural plaque on the left side.

Heart size is normal, hilar and mediastinal contours are normal.

IMPRESSION:

Appearances are in suggestive of asbestosis

BACKGROUND:

Asbestosis represents the formation of interstitial lung disease after exposure to asbestos. Presents with a predominantly male distribution due to historic occupational exposure.

DIFFERENTIAL DIAGNOSIS:

• Other interstitial lung diseases (calcified pleural plaques are fairly specific to asbestos exposure).

FOLLOW-UP:

• None if appearances unchanged
• HRCT and respiratory referral if findings not previously characterised

Question 7

CLINICAL HISTORY:

23yo Female

SOBOE

Answer 7

FINDINGS:

Slight right sided volume loss with a tapering vertical curvilinear opacity in the right lung base, running parallel to the heart border.

Chest appearances are otherwise normal.

IMPRESSION:

Appearances are in keeping with scimitar syndrome.

BACKGROUND:

Scimitar syndrome represents a combination of pulmonary hypoplasia and partial anomalous pulmonary venous return. In the vast majority of cases it is right sided. It may be associated with congenital cardiac abnormalities.

DIFFERENTIAL DIAGNOSIS:

• Pulmonary sequestration
• Right middle lobe atelectasis
• Unilateral absence of pulmonary artery

FOLLOW UP:

Cardiology referral

Consideration of further imaging with ECHO or CT

Question 8

CLINICAL HISTORY:

Significant dyspepsia

Answer 8

FINDINGS:

The oesophagus is grossly dilated with an air-fluid level visualised in the upper mediastinum. Gastric band is seen in the left upper quadrant.

Heart size is normal, normal hilar appearances.

Lungs are clear, no pleural abnormalities.

IMPRESSION:

Megaoesophagus, presumably related to the visualised gastric band.

BACKGROUND:

Diffuse dilation of the oesophagus which may be related to dysmotility or an obstructive cause.

DIFFERENTIAL DIAGNOSIS:

• Ivor Lewis procedure

FOLLOW UP:

• Upper GI opinion / referral
• Consideration of fluoroscopic assessment

Question 9

CLINICAL HISTORY:

36yo Male

Longstanding cough, increasing breathlessness.

No history of smoking

Answer 9

FINDINGS:

Lungs are hyperinflated with visible bullae formation in both lower zones suggesting severe emphysematous change. No pleural abnormalities demonstrated.

Heart size is normal. Normal appearances of the right hilum, the left hilum is bulky but unchanged from previous imaging 10 years ago. Mediastinal contours are normal.

IMPRESSION:

Severe emphysematous disease. Considering patient age consideration should be made to alpha-1-antitrypsin deficiency.

BACKGROUND:

Reduced or absent levels of A1AT results in unchecked activity of neutrophil elastase. This causes the elastase in respiratory structures to be degraded, this is typically more severe in the lower zones due to gravitational blood flow. Pathogenesis may also result in cirrhosis.

DIFFERENTIAL DIAGNOSIS:

• COPD - Consideration should be made to patient age range. True COPD should not present severely in young patients. Additionally COPD usually presents with an upper lobe predominance.
• Ritalin (Methylphenidate) lung - Clinical correlation with history of drug use needed.

FOLLOW UP:

• Respiratory referral if new findings
• Consider HRCT
• Consider U/S abdomen if co-existent cirrhosis suspected
• Blood test for A1AT

Question 10

CLINICAL HISTORY:

30yo Female

Lethargy

Answer 10

FINDINGS:

Anterior mediastinal mass, distension of both paratracheal lines is suggestive of massive lymphadenopathy.

Heart size is normal, the hila are difficult to assess but appear normal.

Lungs are clear, no pleural abnormalities.

IMPRESSION:

Anterior mediastinal mass suggestive of massive lymphadenopathy.

Consideration should be made to lymphoma but further imaging and laboratory testing is required.

(Hodgkin Lymphoma confirmed on biopsy)

BACKGROUND:

Lymphoma is a primary lymphatic malignancy which can be divided into Hodgkin and non-Hodgkin types. Mediastinal manifestations are common. Mediastinal involvement on initial presentation is more common in the Hodgkin type.

DIFFERENTIAL DIAGNOSIS:

Mediastinal lymphadenopathy:

• Very wide differential, but sarcoidosis is commonly considered one of the major differential diagnoses. Sarcoidosis almost always symmetrically involves the hila.

Anterior mediastinal mass:

• Thymoma
• Thyroid malignancy
• Teratoma (or other germ-cell tumours)

FOLLOW UP:

• Blood tests: FBC etc
• Serum ACE for sarcoidosis
• CT CAP

Question 11

CLINICAL HISTORY:

35yo Male

Chest pain and Dyspnoea

Active IVDU

Answer 11

FINDINGS:

Lungs are slightly underinflated.

Multiple cavitating lesions of varying size distributed throughout both lungs with no apparent zonal predominance.

Small/moderate right sided pleural effusion.

The heart appears borderline enlarged but there is no evidence of heart failure. Both hilar contours appear abnormal but this may be due to superimposed lesions. Mediastinal contours are otherwise normal.

Skeletal review is unremarkable.

IMPRESSION:

Given the clinical context appearances are in keeping with multiple septic pulmonary emboli.

BACKGROUND INFORMATION:

• Embolisation of infectious material which is deposited in the lungs via the pulmonary arterial vasculature*
• Can be caused by intravenous drug use, as well as endocarditis, dental disease and infected lines/tubes*
• The variation in nodule size and rapid change in appearances can be explained through repeated episodes of embolic shower*
• Pleural effusions are common and may progress to empyema*
• Patients would usually present clinically with sepsis*

DIFFERENTIAL DIAGNOSIS:

• Cavitating pulmonary metastases (Unlikely in a patient of this age)
• Necrobiotic pulmonary nodules (Clinical history should suggest history of inflammatory bowel disease or rheumatoid arthritis
• Granulomatosis with polyangiitis (Onset is typically later in life (50 years) non-septic presentation)

FOLLOW-UP:

• CT Pulmonary Angiogram for further delineation

Question 12

CLINICAL HISTORY:

95Yo Female

Pyrexia

Answer 12

FINDINGS:

Consolidation in the left mid/lower zone with effacement of the heart border.

Rounded opacification in the left upper zone containing multiple lucent spheres. Associated deformity of the left upper ribs and left sided volume loss.

Calcific changes over the left mid and lower zone which are presumably pleural in nature.

Granulomata in the right perihilar region in keeping with previous granulomatous disease.

IMPRESSION:

Appearances are in keeping with left sided pulmonary infection, which is probably lingular.

Background left upper zone changes are pathognomonic for plombage, right sided granulomata could suggest previous tuberculous infection.

BACKGROUND:

Plombage was a historical treatment for upper lobe cavitating tuberculosis, prior to the widespread introduction of anti-tuberculous medicines. The inserted material collapsed the adjacent lung, theoretically promoting healing.

DIFFERENTIAL DIAGNOSIS:

• None

FOLLOW UP:

• This patient would need a follow-up CXR in 6-8 weeks to check for resolution of infection. Plombage itself does not need any follow-up unless a complication is suspected

Question 13

CLINICAL HISTORY:

18Yo Female

Cough with haemoptysis

Answer 13

FINDINGS:

Large well defined mass superimposed over the right hemidiaphragm, with evidence of cavitation.

Several smaller nodules are seen elsewhere in the right lower zone and left mid zone. No pleural abnormality is demonstrated.

Heart size is normal. Hila and mediastinal contours are normal.

IMPRESSION:

Multiple lung nodules, the largest of which shows evidence of cavitation.

Appearances could represent cavitating infection or granulomatosis with polyangiitis. Given the patient’s age malignancy seems unlikely.

BACKGROUND:

• This case shows granulomatosis with polyangiitis which is a type of necrotising granulomatous vasculitis. GPA has systemic manifestations but the pulmonary symptoms include cough and haemoptysis. In approximately 90% of cases the patient has a positive c-ANCA.*
• CXR appearances include cavitating nodules of various sizes, though cavitation in smaller nodules will be difficult to appreciate. Additionally there may be areas of consolidation which could represent areas of pulmonary haemorrhage.*

DIFFERENTIAL DIAGNOSIS:

• Cavitating pulmonary malignancy
• Cavitating infection - patient should present with septic symptoms

FOLLOW-UP:

• CT with contrast for further delineation, depending on the presence of other systemic symptoms or the likelihood of malignancy, the CT may be limited to the chest or cover the whole torso.
• Laboratory testing for c-ANCA may help to point toward GPA.
• Biopsy may be needed to prove presence of granulomatous vasculitis.

Question 14

CLINICAL HISTORY:

New ITU admission, please confirm ET tube position

Answer 14

FINDINGS:

AP portable projection.

Endotracheal tube in situ with the tip suitably located.

Left sided central line in situ with the tip visualised in the region of the superior vena cava.

Nasogastric tube in situ, the tube is seen to lie outside the borders of the trachea and crosses the carina in a safe zone. the tip is not visualised but lies in the left upper quadrant. Safe for use.

Bilateral consolidation with a symmetrical perihilar and lower zone predominance.

Both hemidiaphragms are effaced, this is likely due to consolidation but it is difficult to rule-out co-existing pleural effusions.

Heart size cannot be accurately assessed but appears grossly normal. Hila are difficult to assess due to overlying consolidation, mediastinal contours appear normal.

IMPRESSION:

All implanted lines and tubes are safe for use.

Bilateral symmetrical consolidation with a perihilar and lower zone predominance.

Appearances are in keeping with ARDS but may also represent diffuse pulmonary haemorrhage, pulmonary oedema or infection. Clinical correlation is advised.

BACKGROUND:

Acute respiratory distress syndrome represents an acute lung injury causing alveolar damage. Alveoli become filled with fluid which decreases oxygenation.

DIFFERENTIAL DIAGNOSIS:

• Pneumonia
• Pulmonary haemorrhage
• Cardiogenic pulmonary oedema - On serial radiographs pulmonary oedema will resolve with diuretic therapy.

FOLLOW-UP:

• CT chest can be used for further delineation if needed

Question 15

CLINICAL HISTORY:

46Yo Female

Left sided chest pain

Answer 15

FINDINGS:

Innumerable tiny nodules demonstrated bilaterally and evenly throughout the lungs. High density suggests calcification.

No acute pulmonary pathology is demonstrated. No pleural abnormalities demonstrated.

Heart size is normal. Hila and mediastinal contours are normal.

Skeletal review is unremarkable.

IMPRESSION:

Appearances are consistent with previous varicella pneumonia.

No cause for patient’s symptoms identified.

BACKGROUND:

Varicella pneumonia is a viral lung infection caused by the chickenpox virus (varicella-zoster). Initial infection will present with multiple nodules, these may resolve but in some cases (as here) calcify. Most cases of pneumonia are in immunocompromised adults.

DIFFERENTIAL DIAGNOSIS:

Correlation with previous post-infection imaging should show unchanged appearances.

DDX of dense miliary opacities:

• Repeated episodes of pulmonary haemorrhage - patient should have clinical history of this.
• Silicosis - Upper lobe and posterior distribution, other appearances supporting pneumoconiosis.
• Pulmonary alveolar microlithiasis - calcification is more confluent. Middle and lower zonal distribution.

FOLLOW-UP:

• If clinical presentation and previous imaging support varicella pneumonia then no f/u is needed.

Question 16

CLINICAL HISTORY:

95Yo Female

Right neck of femur fracture. Pre-operative CXR please

Answer 16

FINDINGS:

AP Semi erect projection. Rotation to the left.

A large teardrop shaped radiopacity is demonstrated over the upper aspect of the right hemithorax. The edge appears calcified. It is unclear if the appearances are iatrogenic or pathological.

Small right sided lamellar pleural effusion. Small left pleural effusion.

Heart size cannot be accurately assessed but appears enlarged, bilateral Kerley-B lines suggestive of cardiac failure.

Degenerative appearance of the spine, no acute fractures are demonstrated in the thorax.

IMPRESSION:

Appearances in keeping with cardiac failure.

Large peripherally calcified opacity over the right hemithorax of uncertain aetiology. Clinical correlation is required, is there any history of pleural disease or surgical intervention?

BACKGROUND:

This case demonstrates an oleothorax which is an antiquated treatment for TB. It was not typically performed after the 1950s and is therefore unlikely to be encountered in clinical practice. The inserted oil is typically removed but if left in situ can result in complications after a long period of time. Complications can include superimposed infection and bronchopleural fistula.

DIFFERENTIAL DIAGNOSIS:

In the absence of previous imaging or appropriate clinical history it is difficult to distinguish an oleothorax from pleural pathology:

• Old empyema or haemothorax with calcification.
• Mesothelioma

FOLLOW-UP:

With correction clinical history or previous imaging no follow-up is needed for oleothorax, unless complications are suspected.

Question 17

CLINICAL HISTORY:

Port-a-cath inserted, ?position

Answer 17

FINDINGS:

Port-a-cath in situ, the tip is demonstrated in the region of the superior vena cava.

Widespread skeletal abnormalities with osteopaenia and expansion deformities of the ribs.

Heart is borderline enlarged. Prominent appearance of hilar vessels, mediastinal contours are otherwise normal.

Lungs are clear, no pleural abnormalities demonstrated.

IMPRESSION:

Port-a-cath is correctly sited and safe for use.

Expansile abnormalies of the ribs, with generalised osteopaenia. Does the patient have an underlying condition to explain this?

BACKGROUND:

This case demonstrates thalassemia, a type of haemoglobinopathy. Inadequate production of globin results in compensatory expansion of red-marrow spaces such as the ribs. Extramedullary haematopoiesis can occur causing lobulated soft tissue lesions on CXR (not present in this case).

DIFFERENTIAL DIAGNOSIS:

• Some lysosomal storage disorders

FOLLOW-UP:

• Correlate with previous imaging, patients are unlikely to present with unknown disease and skeletal changes. In this event a referral to haematology would be indicated.

Question 18

CLINICAL HISTORY:

40Yo Male

SOB for 3/12, pyrexia and cough

Answer 18

FINDINGS:

Bilateral asymmetrical areas of consolidation throughout both lungs, predominantly in the upper and middle zones.

No pleural abnormality is demonstrated.

Heart size is normal. The left hilum is obscured by consolidation, but the right hilum and mediastinal contours are normal.

IMPRESSION:

Appearances are suggestive of an atypical infection or inflammatory process.

BACKGROUND:

This case demonstrates eosinophilic pneumonia. Eosinophilic pneumonias represent eosinophil rich fluid filling alveolar spaces. The cause may be idiopathic, secondary to drug exposure or fungal/parasitic infection, or as part of a vasculitis (Eosinophilic granulomatosis with polyangiitis). Eosinophilic pneumonia can be further divided:

• Simple - transient consolidations which regress and relapse, mild clinical symptoms
• Acute - acute onset of pyrexia, dyspnoea and hypoxia
• Chronic - consolidation persists for more than 6 months
• Idiopathic hypereosinophilic syndrome - similar appearances to simple, but consolidation does not spontaneously resolve

DIFFERENTIAL DIAGNOSIS:

• Chronic aspiration pneumonia
• Pulmonary haemorrhage
• Pulmonary manifestations of vasculitis
• Cryptogenic organising pneumonia

FOLLOW-UP:

Complex pneumonias may need to assessed with HRCT

Blood tests:

• Increased eosinophilia (>1000)
• Increased IgE
• Increased ESR

Question 19

CLINICAL HISTORY:

25Yo Male

Dyspnoea and thoracic pain that worsens with activity

Answer 19

FINDINGS:

Rounded mass superimposed over the left hilum. The mass is continuous with the heart border, and the hilum and descending aorta can be clearly differentiated. Appearances in keeping with an anterior mediastinal mass.

Heart size is normal, right hilum is normal. No evidence of hilar or paratracheal lymphadenopathy.

Lungs are clear, no pleural abnormalities.

IMPRESSION:

Anterior mediastinal mass.

Appearances may represent a thymic tumour or germ cell tumour.

Lymphadenopathy, thyroid tumour and aortic aneurysm are thought less likely, but difficult to exclude entirely.

Further imaging with CT is required.

BACKGROUND:

This case demonstrates a mature cystic teratoma. This is not a diagnosis which can be made on CXR and required a CT and US biopsy. Mediastinal teratomas are a type of germ cell tumour and are the most common extra-gonadal location. They typically present in the 3rd and 4th decades.

DIFFERENTIAL DIAGNOSIS:

• Thymic tumours
• Thyroid tumours
• Lymphoma and lymphadenopathy
• Vascular masses i.e thoracic aortic aneurysm

FOLLOW-UP:

• CT Thorax or CT TAP depending on local policy

Question 20

CLINICAL HISTORY:

25Yo Female

Chest pain and SOB for 2 months

Answer 20

FINDINGS:

Large rounded mass projected over the left mid and lower zones medially. The mass has effaced the descending aorta, but the left hilum and heart border are still visualised. Appearances are in keeping with a posterior mediastinal mass.

Heart size is normal, normal hilar appearances.

Lungs are otherwise clear, no pleural abnormality.

Skeletal review is unremarkable.

IMPRESSION:

Large left sided mass continuous with the posterior mediastinum.

Further imaging is required to investigate.

BACKGROUND:

Schwannomas are a type of benign peripheral nerve sheath tumour. Symptoms typically arise from local mass effect or dysfunction of the associated nerve.

DIFFERENTIAL DIAGNOSIS:

• Chest malignancy
• Other non-malignant tumours, i.e hamartoma (most are smaller than this)

FOLLOW-UP:

• CT Thorax is typical second line investigation
• MRI Thorax if Schwannoma is suspected on CT

Question 21

CLINICAL HISTORY:

Reduced breath sounds left lung

Answer 21

FINDINGS:

Complete whiteout of the left hemithorax. The right lung appears hyperinflated but clear.

Significant tracheal, mediastinal and diaphragmatic shift into the left hemithorax.

Surgical clips in the hilar region.

Heart size, hila and mediastinal contours cannot be assessed.

IMPRESSION:

Appearances are in keeping with a left pneumonectomy.

BACKGROUND:

• Pneumonectomy is the surgical removal on an entire lung, commonly for lung malignancy.*
• Comparison with previous imaging is important to rule out complications such as bronchopleural fistula.*
• Radiographic appearances are variable depending on the time since the surgery was performed.*

DIFFERENTIAL DIAGNOSIS:

• Total collapse of the lung would typically result in less shift of structures.
• Hilar clips show evidence of surgery.
• Massive pleural effusion results in contralateral displacement of the mediastinum.

FOLLOW-UP:

• None if appearances are stable.

Question 22

CLINICAL HISTORY:

Cough, breathless for many years

Answer 22

FINDINGS:

Bilateral reticular interstitial shadowing in both upper zones, with several irregular mass-like structures present. No pleural abnormalities are demonstrated.

Hila are superiorly displaced in keeping with upper lobe volume loss bilaterally. The heart is enlarged, but no evidence of cardiac failure.

IMPRESSION:

Appearances are suggestive of a pneumoconiosis with pulmonary massive fibrosis. However, in the absence of previous imaging malignancy needs to be excluded.

BACKGROUND:

This radiograph demonstrates silicosis. Silicosis can have variable radiographic appearances depending on if it is seen in an acute, classic simple or classic complicated setting. This case is classic complicated silicosis as it also features the mass-like appearances of pulmonary massive fibrosis. PMF represents the coalescence of areas of fibrosis and is a fairly specific complication of pneumoconioses.

DIFFERENTIAL DIAGNOSIS:

Background silicosis appearances have a differential of other pneumoconioses:

• Coal workers’ pneumoconiosis
• Talcosis

Presence of PMF has the same differentials but with the addition of:

• Late-stage sarcoidosis
• Malignancy

FOLLOW-UP:

• Comparison with previous imaging, if available. PMF develops slowly and lesions will migrate towards the hila over time.
• Clinical correlation with occupation exposure.
• In the absence of previous imaging or if there are clinical red-flags for malignancy then CT is indicated to assess.

Question 23

CLINICAL HISTORY:

25Yo Female

NBO, abdominal pain ?obstruction

Answer 23

FINDINGS:

Normal calibre of small and large bowel, no evidence of obstruction.

A small radiopacity is demonstrated over the left side of the sacrum suggestive of a tooth. This would be in keeping with an ovarian teratoma.

Skeletal review is unremarkable.

IMPRESSION:

No evidence of bowel obstruction.

Incidental finding of probable ovarian teratoma. In the context of abdominal pain an ultrasound is suggested to exclude complications.

BACKGROUND:

Ovarian teratomas (also referred to as dermoid cysts) are the most common ovarian neoplasm. Most are classified as mature, immature teratomas have a higher incidence of malignant transformation. Unless the cells differentiate into a radiopaque structure, i.e teeth as in this case, they will not be visible on AXR unless they grow large enough to cause mass-effect.

DIFFERENTIAL DIAGNOSIS:

• On AXR there are no pathological differentials.
• Ingested tooth could present in a similar fashion, but the tooth would be visibly over bowel and there would be correlating clinical history.

FOLLOW-UP:

• Ultrasound as initial assessment

Question 24

CLINICAL HISTORY:

70Yo Male

Cough 3 weeks

Answer 24

FINDINGS:

Atelectasis and volume loss in the left upper zone and apex with superior displacement of the left hilum and hemidiaphragm.

Surgical clips at the left hilum. Normal appearances of the right hilum.

Heart size is indeterminate, but no gross enlargement is demonstrated. Calcific changes within the aortic arch, mediastinal contours are normal.

No acute pulmonary pathology is demonstrated, no pleural abnormalities.

IMPRESSION:

Appearances are in keeping with left upper lobectomy.

BACKGROUND:

Lobectomy is the removal of an entire lung lobe and is commonly performed for primary lung malignancy. Volume loss will cause shift of structures such as the diaphragm or hila towards the surgical site. Lobectomy can result in post-surgical complications such as ARDS or haemothorax, these typically occur in the early or mid post-operative period. Broncho-pleural fistula may occur but is less common relative to total pneumonectomy.

DIFFERENTIAL DIAGNOSIS:

• Lobar collapse (left upper lobe in this case) - Presence of surgical clips at hilum, appropriate clinical history and comparison with previous imaging should exclude this.

FOLLOW-UP:

• None unless complications are suspected.

Question 25

CLINICAL HISTORY:

35Yo Male

Asthmatic, new SOB ?exacerbation

Answer 25

FINDINGS:

Branching opacification in the right upper zone in keeping with bronchoceles. Subtle bronchiectasis in the left upper zone.

No pleural abnormalities demonstrated.

Heart size is normal, hilar and mediastinal contours are normal.

IMPRESSION:

Bronchoceles right upper zone, bronchiectaisis left upper zone.

BACKGROUND:

This case demonstrates allergic bronchopulmonary aspergillosis (ABPA). ABPA represents a hypersensitivity reaction to Aspergillus inhalation, it typically occurs on a background of chronic lung disease (usually asthma) and usually before the age of 40 years. Radiographic appearances are variable depending on stage; the CXR may appear normal or present with patchy opacification in early stages. Once bronchiectasis has developed this may be visualised, in this case there is mucoid impaction of bronchiectasis (bronchocele) this is known as a “finger in glove sign”.

DIFFERENTIAL DIAGNOSIS:

Presence of bronchiectasis has a wide differential, typically it is central in ABPA:

• In a young patient the main differential would be cystic fibrosis (this should be relatively easy to clinically correlate)

Presence of fleeting patchy consolidation:

• Eosinophilic pneumonia

Bronchocele:

• Multiple causes of various aetiologies

FOLLOW-UP:

• Consider HRCT to further delineate
• If ABPA is suspected an aspergillus specific IgE will be elevated

Question 26

CLINICAL HISTORY:

54Yo Female

Abdominal pain and distention

Answer 26

FINDINGS:

Hazy shadowing throughout the abdomen. The normal borders of the liver and spleen are effaced.

Bowel is displaced centrally but appears of normal calibre, no evidence of obstruction.

IMPRESSION:

Appearances are in keeping with ascites, no evidence of bowel obstruction.

BACKGROUND:

• Ascites represents an accumulation of peritoneal fluid. Typically, the term is reserved for large amounts of fluid, as a small volume is normally present within the abdomen. Similar to a pleural effusion they can be classified as transudates or exudates depending on protein count and specific gravity.*
• Appearance on AXR of:*
• Diffuse increased density of the abdomen
• Poor definition of organ edges
• Bulging of flanks
• Medial displacement of bowel and solid viscera

DIFFERENTIAL DIAGNOSIS:

Specific types of fluid in the peritoneal cavity, appearances are identical on AXR:

• Chyloperitoneum
• Haemoperitoneum
• Leak of fluid from biliary or urinary bladder injury

FOLLOW-UP:

• If ascites is previously unknown then further imaging is indicated to determine cause

Question 27

CLINICAL HISTORY:

86Yo Male

Pre-op CXR

Answer 27

FINDINGS:

Deformity of the right upper chest wall and ribs. Mediastinal shift to the right and superior displacement of the right hilum. Complete opacification of the right upper zone, fibrotic appearances inferior to this.

The left lung is clear, no pleural abnormalities.

Cardiomegaly, but no evidence of heart failure.

IMPRESSION:

Right upper lobe collapse, presence of adjacent fibrosis and chest wall/rib abnormalities suggest a post-surgical cause. Is there any history of this?

BACKGROUND:

This case shows a thoracoplasty which represents a previous surgical treatment for TB. Thoracoplasty is rarely performed in modern medicine. Plombage represents a sub-type of thoracoplasty. In typical thoracoplasties ribs are removed in order to collapse the underlying lung tissue.

DIFFERENTIAL DIAGNOSIS:

• Lobectomy - Less or no ribs are removed

FOLLOW-UP:

• None required unless complications are suspected

Question 28

CLINICAL HISTORY:

17Yo Male

Cough with haemoptysis

Answer 28

FINDINGS:

Innumerable lung nodules of varying size bilaterally. No pleural abnormality is demonstrated.

The heart border and mediastinal contours are effaced but appear grossly normal.

IMPRESSION:

Appearances are in keeping with multiple pulmonary metastases.

BACKGROUND:

Multiple pulmonary metastases of this appearance are typically referred to as cannonball metastases. Classically these are associated with renal cell carcinoma and choriocarcinoma. In this case the primary tumour is a testicular choriocarcinoma. This would be more expected in a patient of this age than RCC.

DIFFERENTIAL DIAGNOSIS:

Multiple pulmonary nodules (>5mm):

• Septic emboli (correlating clinical history of sepsis, nodules cavitate)
• Fungal infections such as histoplasmosis, coccidiomycosis and aspergillosis (the latter is unlikely to cause this many lesions)
• Hydatid disease (unlikely to cause this many lesions)
• Inflammatory and immunological pathologies can cause multiple large nodules, but other supporting clinical factors and radiological appearances would be present.

FOLLOW-UP:

• CT CAP for delineation and staging

Question 29

CLINICAL HISTORY:

70Yo Female

Long smoking history, new cough

Answer 29

FINDINGS:

Rounded opacity in the left lung apex with associated cresenteric lucency suggestive of monod sign. Associated left upper lobe volume loss with superior displacement of the hila.

Pleuro-parenchymal changes in the right lung apex with volume loss.

No pleural abnormalities are demonstrated. Heart size and mediastinal contours are difficult to assess but grossly normal. Elevated but normal appearance of the right hilum.

IMPRESSION:

Appearance of monod sign in left lung apex, in keeping with aspergilloma.

BACKGROUND:

Aspergillomas represent balls of fungus (aspergillus fumigatus). They typically occur in patients who have normal immunity levels but have atypical lung architecture due to a history of TB, sarcoidosis etc.

DIFFERENTIAL DIAGNOSIS:

• Fairly classical appearance with monod sign has little differential
• With no monod sign the bigggest differential would be malignancy

FOLLOW-UP:

• Further delineation with CT is required +/- contrast depending on likelihood of malignancy vs aspergilloma

Question 30

CLINICAL HISTORY:

65Yo Female

Longstanding cough, painful swollen fingers

Answer 30

FINDINGS:

Lungs appear underinflated. Bilateral reticular interstitial shadowing with a lower zone predominance. These appear particularly prominent in the right lung base.

No pleural abnormalities are demonstrated. Heart size is normal, hilar and mediastinal contours are normal.

IMPRESSION:

Appearances consistent with interstitial lung disease. HRCT is suggested for further delineation.

BACKGROUND:

This case shows rheumatoid lung disease, which is a pulmonary manifestation of RA. The given clinical history of painful swollen fingers could steer the reporter towards this conclusion though the interstitial changes are difficult to distinguish from idiopathic pulmonary fibrosis. Rheumatoid lung nodules may also form but are difficult to appreciate on CXR. Pleural involvement is common and manifests as pleural thickening or effusion (not present in this case). Erosive arthropathy may also be present at the periphery of the image (not present in this case).

DIFFERENTIAL DIAGNOSIS:

• Interstitial lung disease - mainly IPF

FOLLOW-UP:

• HRCT to delineate

Question 31

CLINICAL HISTORY:

53Yo Male

Pyrexia and cough

Answer 31

FINDINGS:

Large cavitating mass in the right upper zone. The mass has a relatively thick margin and an internal air-fluid level.

The left lung is clear, no pleural abnormality is demonstrated.

Heart size and mediastinal contours are normal. Normal hilar appearances, no evidence of lymphadenopathy.

IMPRESSION:

Large cavitating mass in the right upper zone with air fluid level. Appearances are in keeping with cavitating malignancy or lung abscess. Patient presentation would favour the latter.

BACKGROUND:

This case shows a lung abscess which represents a collection of pus within a lung. The incidence of lung abscess is generally low but immunocompromised individuals are more susceptible. They can be classified as acute (<6 weeks) or chronic (>6 weeks). Additionally, classification can also be made into primary when it represents direct infection, or secondary when the infection has spread due to direct extension or haematogenous seeding. The most common cause of abscess is aspiration.

DIFFERENTIAL DIAGNOSIS:

• Empyema (an empyema is pleural and thus should not appear well circumscribed at its entire circumference, though this is difficult to exclude on one projection)
• Cavitating malignancy (either bronchogenic primary or metastasis)
• Cavitating granulomatous disease
• Cavitating infection i.e TB
• In some cases a hiatus hernia can simulate a retrocardiac abscess

FOLLOW-UP:

• CT for further delineation

Question 32

CLINICAL HISTORY:

Answer 32

FINDINGS:

IMPRESSION:

BACKGROUND:

DIFFERENTIAL DIAGNOSIS:

FOLLOW-UP:

Question 33

CLINICAL HISTORY:

Answer 33

FINDINGS:

IMPRESSION:

BACKGROUND:

DIFFERENTIAL DIAGNOSIS:

FOLLOW-UP: