Airway Antics
A 30-year-old man presents to his GP with a cough and increasing shortness of breath. A chest radiograph (CXR) reveals the presence of symmetrical hilar masses. These masses have a lobulated and well-defined outline with some fine peripheral calcification. The lesions do not appear cystic or contain any fat. The only occupational exposure of note is that the patient keeps birds in his house. Which is the most likely diagnosis?
A Mature mediastinal teratoma
B Primary tuberculosis
C Sarcoidosis
D Silicosis
E Untreated lymphoma
C Sarcoidosis
Sarcoidosis is a disease of young adults commonly presenting with bilateral symmetrical lymphadenopathy; only occasionally appearing in an asymmetrical distribution.
A young man is involved in a road traffic accident and complains of pleuritic chest pain and shortness of breath. An initial supine CXR performed in the Emergency Department demonstrates several left-sided posterior rib fractures. There is also the suspicion that a pneumothorax is present. Once stabilised, the patient attends the Radiology Department for an erect PA chest radiograph. Which one of the following signs not seen on the initial supine film will now predominate?
A A deep left costophrenic recess laterally
B Left apical transradiancy and pleural line
C Undue clarity of the left mediastinal border
D Unilateral left lung transradiancy
E Visualisation of the undersurface of the heart
B Left apical transradiancy and pleural line
Typical signs of a pneumothorax are seen on the erect radiograph where pleural air rises to the apex. Here the visceral pleural line at the apex becomes separated from the chest wall by a transradiant zone devoid of vessels.
A 7-year-old girl, who has recently migrated to this country from India, presents with a productive cough, fever, night sweats and weight loss. A CXR demonstrates marked consolidation in the right upper lobe. Sputum cytology reveals the presence of acid fast bacilli. What additional radiological finding is most likely to suggest a diagnosis of current primary tuberculosis as opposed to post-primary tuberculosis?
A Cavitation
B Mediastinal lymphadenopathy
C Multifocal lesions
D Ranke complex
E Rasmussen aneutysm
B Mediastinal lymphadenopathy
Primary tuberculosis causes a pneumonia that mimics Streptococcus pneumoniae in its radiographic appearance and, in children, lymphadenopathy is the most common manifestation.
HISTORY: A 61-year-old woman with cough and dyspnea (See pic 2)
Reverse Golden S sign - Right upper lobe collapse caused by
primary lung neoplasm
A previously fit and well 30-year-old woman undergoes a CT pulmonary angiogram (CTPA) for suspected acute pulmonary embolism. The CTPA excludes a pulmonary embolism but an incidental mediastinal mass is noted. This solitary mediastinal mass is seen inferior to the carina with displacement of the carina anteriorly and the oesophagus displaced posteriorly. The contents of the lesion are of uniform attenuation 0 Hounsfield Units (HU). Prior to this admission the patient had not reported any symptoms of note. What is the most likely diagnosis?
A Bronchogenic cyst
B Mediastinal pancreatic pseudocyst
C Neurenteric cyst
D Neurogenic tumour
E Oesophageal duplication cyst
A Bronchogenic cyst
Bronchogenic cysts are the most common intrathoracic foregut cyst.
A 27-year-old, previously fit and well man presents to his GP with a short history of pyrexia, cough and haemoptysis. He has never previously been admitted to hospital. Sputum culture has grown Streptococcus pneumonia. What is the most likely chest radiograph finding?
A Bronchopneumonia
B Cavitation
C Empyema
D Large pleural effusion
E Lobar consolidation
E Lobar consolidation
Many community-acquired pneumonias are caused by Streptococcus pneumoniae with radiographic features of peripheral, homogeneous opacification. Air bronchograms may be present, but cavitation and empyema are uncommon.
A 70-year-old man recently underwent a laparoscopic prostatectomy. He now presents to the Emergency Department complaining of shortness of breath, pleuritic chest pain and haemoptysis. D-dimer levels were measured and found to be significantly elevated. A CXR is performed as part of the initial set of investigations. Which one of the following is the most likely CXR finding?
A A normal chest radiograph
B Linear atelectasis
C Localised peripheral oligaemia
D Peripheral airspace opacification
E Pleural effusion
A normal chest radiograph is the most common finding in the setting of a
suspected pulmonary embolus (PE).
HISTORY: A 28-year-old asymptomatic man, routine chest radiograph (see pic 4)
A. TB
B. Lung cancer
C. Sarcoidosis
D. Hypersensitivity pneumonitis
C. Sarcoidosis
Classic HRCT findings include well-defined nodules along the interlobular septa, peribronchovascular bundles, and pleural surfaces and smooth or nodular peribronchovascular thickening. Subpleural and peri-fissural nodules are important in distinguishing sarcoidosis from the centrilobular nodules of hypersensitivity pneumonitis.
A 40-year-old woman has a previous histoiy of histoplasmosis. She undergoes a chest CT which demonstrates confluent soft tissue infiltration throughout the mediastinum. Tissue biopsy determines a diagnosis of fibrosing mediastinitis subsequent to the histoplasmosis infection. Which one of the following complications would be the most common to occur?
A Oesophageal obstruction
B Pulmonary artery obstruction
C Pulmonary venous obstruction
D Superior vena cava obstruction
E Tracheal obstruction
D Superior vena cava obstruction
Superior vena cava obstruction is the most common complication of fibrosing mediastinitis, but occasionally it can present with pulmonary arterial obstruction, pulmonary venous obstruction (peribronchial obstruction, septal lines etc), central airway narrowing (stridor) and oesophageal narrowing (dysphagia).
A 38-year-old man is referred to a chest physician for evaluation of a chronic productive cough. Over the past 10 years he has experienced increased expectoration of mucoid sputum that became purulent during infective exacerbations. On plain radiography the trachea had a corrugated outline. CT evaluation revealed dilatation of the trachea and mainstream bronchi.Which one of the following is the most likely diagnosis?
A Amyloidosis
B Mounier-Kuhn disease
C Relapsing polychondritis
D Tracheal leiomyoma
E Wegener's granulomatosis
B Mounier-Kuhn disease
Mounier-Kuhn disease (tracheobronchomegaly) describes patients with marked dilatation of the trachea and mainstream bronchi and is a radiological diagnosis.
A previously fit and well 50-year-old man presents with progressive dyspnoea for one year. On CXR, there are bilateral, peripheral reticular opacities seen at the lung bases. On HRCT chest, there is a subpleural basal reticular pattern with areas of honeycomb change seen. Which one of the following is the most likely diagnosis?
A Acute interstitial pneumonia (AIP)
B Cryptogenic organising pneumonia (COP)
C Desquamative interstitial pneumonia (DIP)
D Nonspecific interstitial pneumonia (NSIP)
E Usual interstitial pneumonia (UIP)
E Usual interstitial pneumonia (UIP)
The above HRCT findings are almost pathognomonic for UIP and when a confident diagnosis of UIP is made on HRCT it is usually correct.
A 60-year-old man, with a known history of asbestos exposure, is seen in the chest outpatient clinic with increasing shortness of breath. A CT chest is performed and demonstrates a subpleural mass in the right lower lobe with thickening of the adjacent pleura. Which additional radiological finding is most likely to reassure you that this is not a bronchogenic carcinoma?
A An acute angle made by the mass with the surrounding pleura
B ‘Comet tail’ sign
C Homogeneous contrast enhancement
D The lesion is solitary
E Volume loss in the lower lobe
B ‘Comet tail’ sign "see pic 1"
Round atelectasis (folded lung) is a benign condition seen in patients exposed to asbestos.
Aspergilloma
A 30-year-old male nonsmoker presents to his GP with a three-month history of intermittent episodes of cough and wheeze. Initially diagnosed as having asthma, the patient was found to be a 1-antitrypsin deficient after mentioning that several relatives have had similar problems in the past. As part of the subsequent investigations, an HRCT chest was performed. Which finding is most consistent with this clinical scenario?
A Low attenuation regions with a lower lobe predominance
B Low attenuation regions with an upper lobe predominance
C Pleural effusion
D Spontaneous pneumothorax
E Subpleural low attenuation areas
A Low attenuation regions with a lower lobe predominance
Panlobular emphysema is seen in al-antitrypsin deficiency. The disease tends to occur in a lower lobe distribution (unless there is a smoking history, where an upper lobe predominance can be seen).
Spotter (see pic 7)
Pulmonary arterial hypertension
Spotter (see pic 9)
Right middle lobe bronchiectasis (Myobactrium avium complex infection) Lady Windermere syndrome
Plain radiograph
Linear opacities in middle lobe or lingula can be seen, as a result of subsegmental atelectasis or bronchiectasis with mucosal impactions. Residual middle lobe or lingula atelectasis can also be seen.
CT
Typical manifestation is of bronchiectasis, centrilobular nodules, tree-in-bud nodularity and eventual scarring and volume loss affecting the middle lobe and lingula. It is one of the causes of right middle lobe syndrome.
Spotter (see pic 11)
Necrotizing pneumonia refers to pneumonia characterized by the development of necrosis within infected lung tissue.
If a necrotizing infection is suspected, contrasted CT thorax allows appreciation of areas with low attenuation and non-enhancement within the necrotic portions.
CT imaging may show distinct areas of low attenuation with decreased parenchymal enhancement (representing liquefaction 8) in all or parts of the affected area of infection (consolidation). Normal pulmonary parenchymal architecture within the necrotic segment is often lost 1.
An 80-year-old man has been admitted to hospital with shortness of breath and a productive, purulent cough. A CXR reveals left lower lobe consolidation. Which additional radiological finding is most likely to suggest a diagnosis of Klebsiella pneumoniae rather than Legionella pneumophildi?
A Bulging fissures
B Mediastinal lymphadenopathy
C Pleural effusion
D Pneumothorax
E Septal thickening
A Bulging fissures
Klebsiella pneumoniae leads to an extensive exudative response leading to cavitating lobar consolidation and bulging fissures. Legionnaire's disease, on the other hand, tends to present with multifocal lobar, homogeneous opacities with a tendency to appear like masses.
Spotter (see pic 10)
Descending necrotizing mediastinitis is a severe form of mediastinitis and refers to an acute, polymicrobial infection of the mediastinum that usually spreads downwards from oropharyngeal, cervical, and odontogenic infection.
Plain radiograph
Neck radiography may show subcutaneous emphysema, prevertebral soft-tissue swelling, mediastinal gas, and/or superior mediastinal widening.
CT
CT chest may show mediastinal gas +/- fluid collections. Accompanying CT neck findings include thickening of the subcutaneous tissues in the neck, thickening or enhancement of cervical fascia and muscles, fluid collections, and enlarged lymph nodes.
A 25-year-old asthmatic man is referred to the chest outpatient clinic with a fever, cough and shortness of breath. A course of antibiotics has not improved his symptoms. Investigations performed in the clinic include a positive skin test for Aspergillus jumigatus and an elevated serum IgE. The patient is known to be immunocompetent with no previous history of sarcoidosis or tuberculosis. Which one of the following are the most likely high-resolution CT (HRCT) findings?
A A lower lobe predominance
B An air crescent sign
C Central bronchiectasis
D The halo sign
E Wedge-shaped peripheral infarcts
C Central bronchiectasis
Allergic bronchopulmonary aspergillosis (ABPA) is part of a spectrum of disease caused by Aspergillus fumigatus. Hypersensitive individuals (commonly those with asthma) can present with ABPA and the key radiological features are central airway mucoid impaction leading to central bronchiectasis.
HISTORY: A 57-year-old woman with a history of breast carcinoma (see pic 3)
A. Pulmonary Edema
B. Lymphangitic carcinomatosis
C. Viral pneumonia
D. Sarcoidosis
B. Lymphangitic carcinomatosis
Lymphangitic spread of tumor in the lung is a relatively rare metastatic pattern, typically to the result of adenocarcinomas. The tumor cells are deposited in the lung periphery by hematogenous dissemination and then, rather than forming the typical nodule, infiltrate the pulmonary lymphatics and interlobular septa growing back toward the hila, producing thickening of the interlobular septa and peribronchovascular interstitium.
Sarcoidosis may mimic this radiographic appearance, the patient’s clinical presentation and past medical history should allow for confident distinction of the two. In particular, the presence of uni- lateral disease or pleural effusion strongly favors lymphangitic carcinoma.
Lung cancer and treatment of lung cancer with radiation therapy may lead to central venous and lymphatic obstruction that may result in interstitial opacities
HISTORY: A 72-year-old World War II veteran with abnormal chest radiography results. (see pic 6)
A. Hypersensitivity pneumonitis
B. Sarcoidosis
C. Silicosis
D. Asbestosis
D. Asbestosis
Volume loss in the involved lobe and comet tail appearance of vessels and bronchi around the mass are classic for helical atelectasis.
An 80-year-old lifelong male smoker presents with a cough and wheeze. A CXR demonstrates right middle lobe airspace opacification with bulging of the central oblique and horizontal fissures. The radiographic appearances fail to resolve 4 weeks later, after an appropriate course of antibiotics. CT evaluation demonstrates a large cavitating centrally placed mass. Which one of the following diagnoses is the most likely?
A Adenocarcinoma
B Large cell carcinoma
C Lymphoma
D Small cell carcinoma
E Squamous cell carcinoma
E Squamous cell carcinoma
In lung cancer, the radiological pattern of disease varies with the cell type. Squamous cell tumours are the most common tumour to cavitate and those most frequently associated with collapse/consolidation of the lung due to their predominantly central location.
A 50-year-old lifelong male smoker has presented to his GP with increasing shortness of breath. A CXR shows that the right atrial border is a little indistinct. On the lateral view there is a triangular density with its apex directed towards the lung hilum. Which one of the following is the most likely diagnosis?
A Left lower lobe collapse
B Left upper lobe collapse
C Right middle lobe collapse
D Right lower lobe collapse
E Right upper lobe collapse
C Right middle lobe collapse
The collapsed right middle lobe will lie adjacent to the right heart border and as there is no longer a clear heart—lung interface, then the right heart border appears indistinct.
HISTORY: A 67-year-old man with dyspnea who has worked as a concrete driller for many years. (see pic 5)
A. Pneumoconiosis
B. Sarcoidosis
C. Silicosis
D. Asbestosis
C. silicosis
Silicosis causes upper lobe nodules and conglomerate masses with egg-shell calcification.