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Atlas of DIAGNOSTIC RADIOLOGY

Atlas of DIAGNOSTIC RADIOLOGY

Khalid Mahmood

MBBS, FCPS, MACG

Professor and Chair Department of Medicine Dow University of Health Sciences Karachi, Pakistan

Foreword

Paul R Goddard

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Atlas of Diagnostic Radiology

© 2009, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2009 ISBN: 978-81-8448-670-4

Typeset at

JPBMP typesetting unit

Printed at

Ajanta Press

To My parents, all my achievements are because of their affection, efforts, encouragement and prayers

Contributors
Contributors

Kashif Burney MBBS MRCS(Eng.) FRCR

Consultant Interventional Radiologist St Helier University Hospital Wrythe Lane, Carshalton Surrey, UK

Sikandar Rafique Qureshi MBBS MCPS

Chief/Head Radiologist Civil Hospital, Karachi, Pakistan

Zahid Anwar Khan MBBS MCPS FCPS FRCR

Ex. Professor Head Radiology Department Sindh Institute of Urology and Transplant (SIUT) Karachi, Pakistan

Qurat-ul-Ain MBBS FCPS (Radiology)

Consultant Radiologist Aga Khan University Hospital Karachi, Pakistan

Asima Shakoor MBBS FCPS (Medicine)

Registrar Medicine Dow Medical College, Civil Hospital Karachi, Pakistan

Abdul Wahid Shaikh

Clinical Research Fellow Department of Medicine Dow University of Health Sciences Karachi, Pakistan

Farooq M Husain

Registrar Medicine Dow University of Health Sciences Civil Hospital, Karachi, Pakistan

Foreword
Foreword

Roentgen’s discovery of X-rays in 1895 heralded the modern age of medicine. Before that time, there was no way of examining the internal structures of the body without resorting to surgery. Since that discovery, we have been able to look at in vivo anatomy and pathology in increasingly exquisite detail using a variety of sophisticated techniques. Despite this, the mainstay of diagnostic imaging for many parts of the body still remains the humble plain radiograph.

Even though the techniques of medical imaging are widely available, their interpretation skill relies on the knowledge and ability of the examiner which in turn largely depends on experience.

But how can a student obtain this experience? Partly, this must be with direct patient involvement, but this can be considerably assisted by well-presented museum cases.

This atlas provides such an archive in a readily accessible form and with sufficient clinical details that each case assists in the building of the knowledge base. The case mix has been chosen to represent the prevalent disease pattern. As such, this will not only be a valuable resource for its target audience of local undergraduate and postgraduate students but will also be of inestimable value to post-graduate students of medicine and their tutors in the parts of the world where the conditions shown may be less frequently encountered.

The brief but salient account of the radiological features of the conditions provides a good introduction to each section. The films include many plain radiographs, contrast examinations, computed tomography and a few magnetic resonance imaging scans. In each case the images presented show the abnormality clearly. Some of the studies are less perfect than others but this is the reality of life. Too many books show only perfect cases giving the impression that this is how we should expect to see the cases. In practice the quality of images obtained depends on a large variety of factors including age of equipment, radiographic expertise and the condition of the patient. These cases thus represent the mix of

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Atlas of Diagnostic Radiology

images that the student is likely to meet and provide a superb resource which will help to hone the necessary interpretive skills.

Professor Mahmood must be congratulated on having collected such an interesting and useful museum of films and the atlas is testament to his excellent relationships with his radiological colleagues.

Professor Paul R Goddard

BSc, MBBS, MD, DMRD, FRCR

(Retd.) Consultant and Head of Training Bristol Radiology Training Scheme Civil Consultant to the Royal Air Force (Honorary Air Commodore) Past-President of the Radiology Section of the Royal Society of Medicine Visiting Professor University of the West England

Preface
Preface

Three simultaneous roles as a physician, teacher and examiner propelled my search for radiological films with definite findings. This led to a virtual treasure of films from not only my own patients but even my colleagues. Practising for over twenty-five years, I now felt myself in a position to meticulously plan an Atlas. An Atlas of medical radiology may sound as a misnomer to many but significant and valuable technical input from my radiologists should make this book reader friendly. As 20% of X-rays are more than 20 years old, they are not of high quality yet have been included to make the compilation complete. Diverse presentations of diseases have been illustrated by multiple X-rays of single diseases. Tuberculosis being a case in point, its high prevalence and multisystem involvement has many X-rays to present a complete spectrum of disease. Salient features of common diseases have been added at the beginning of the chapters for the benefit of students. Detailed description was beyond the scope of this book. The atlas has been divided into chapters on Pulmonology, Cardiology, Barium Studies, Musculoskeletal System, Abdomen including Intravenous Urographies and lastly CT and MRIs of Brain. In this era of rapid advance- ment in radiology and imaging, this atlas would be considered more conventional. As undergraduate and postgraduate students of medicine are targeted for readership, I hope it proves valuable. The newer imaging technologies are not covered as this would require a bulkier offering, but have been indicated where of value.

Khalid Mahmood

Acknowledgements
Acknowledgements

It would be remiss if I did not thank all those who have helped me in putting together this atlas. The compilation of this Atlas would not have been possible without the hard work and sincere contribution of my juniors Dr Uzma Ghaury, Dr Asima Shakoor, Dr Abdul Wahid Shaikh and Dr Farooq M Husain for which I will remain thankful to them. I cannot forget the technical help extended by Dr Sikandar Qureshi, Dr Qurat-ul-Ain and Dr Kashif Burney for which I am grateful. I must not forget to thank Professor Paul R Goddard for taking out some of his very precious time to go through the manuscript and write its foreword.

Contents
Contents
  • 1. Pulmonology

1

Introduction

2

Pulmonary tuberculosis

17

Aspergillosis

36

40

45

62

Bronchiectasis

Consolidation ...................................................................................................

Hydatid cyst of lung

Pleural effusion

64

Pneumothorax

69

Pulmonary neoplasm

74

95

 

100

106

Cavitating lesions

108

Mediastinal mass

112

Pulmonary miscellaneous

118

  • 2. Cardiology

123

Introduction

124

Congenital heart disease

132

Valvular heart diseases

138

Pericardial diseases

142

145

148

153

  • 3. Barium Studies and Oral Cholecystography

157

Introduction

158

Barium esophagus

165

Barium stomach

177

Barium duodenum

192

Barium follow through

195

Barium enema

203

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Atlas of Diagnostic Radiology

  • 4. Skeletal System

217

Introduction

218

Skeletal congenital anomaly

230

Metabolic bone disorders

234

Inflammatory joint diseases

245

Bone infections

261

Hematological bone diseases

275

Skeletal neoplasm

280

Skeletal miscellaneous

286

  • 5. Plain Abdomen and Intravenous Pyelograms

295

Introduction

296

Abdomen

300

Intravenous urographies

312

  • 6. Brain

321

Introduction

322

Infections ........................................................................................................

331

Cerebrovascular diseases

340

Brain neoplasms

352

Index

365

Pulmonology

1

2
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Atlas of Diagnostic Radiology

PULMONARY TUBERCULOSIS

PRIMARY TUBERCULOSIS

Chest radiograph may appear entirely normal. Predominant feature is unilateral hilar and adjacent mediastinal adenopathy. Pulmonary focus is randomly distributed and may range from a small ill-defined shadow to segmental or lobar consolidation, commonly on the right side. Pulmonary focus may show calcification and may rarely cavitate. Airway narrowing secondary to extrinsic nodal compression with resultant atelectasis may occur (e.g. Brock’s syndrome). Primary tuberculosis may also present as pleural effusion or pleural thickening. Miliary tuberculosis can occur as a complication.

POST-PRIMARY/SECONDARY/REACTIVATION TB

Calcified primary complex may be identified. The disease can be unilateral or bilateral and apical/posterior segments of the upper lobes or superior segments of the lower lobes are most often involved. Patchy foci of air- space disease “cotton-wool shadows” are characteristic. Pulmonary foci may cavitate, and multiple cavities of varying sizes may be present. Fluid levels may aid in recognition of cavities, the walls of which may be indistinct or obscured by overlying densities. Pneumothorax may occur. Scattered calcifications, fibrous contraction leading to hilar retraction and lobar volume reduction are seen in chronic cases. Lobar consolidation may occur. Dissemination via the airways presents as bronchopneumonia. Dissemination via the blood can cause miliary infiltrates. Involvement of pleura can cause diffuse pleural thickening, effusions, empyema, pneumothorax, bronchopleural fistula and eventually calcified pleura (fibrothorax). Endobronchial tuberculosis—ulcers and strictures, bronchial obstruction leading to collapse or hyperinflation, may also present as bronchiectasis. Single or multiple tuberculomata of variable sizes can also occur.

BIBLIOGRAPHY

  • 1. Delacourt C, Mamou Mani T, Bonnerot V, De Blic J, Sayeg N, Lallemand D, et al. Computed tomography with normal chest radiograph in tuberculous infection, Arch Dis Childhood. 1993; 69:430-2.

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3

  • 3. Ip MSM, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest 1986;89:727-30.

  • 4. Lee KS, Song KS, Lim TH, Kim PN, Lee BH. Adult-onset pulmonary tuberculosis: Findings on chest radiographs and CT scans. AJR Am J Roentgenol. 1993;160:753-
    8.

  • 5. Leung AN, Muller N, Pineda PR, Fitzgerald JM. Primary tuberculosis in child- hood: Radiographic manifestations. Radiology 1992;182:87-91.

  • 6. Palmer PES. Pulmonary tuberculosis: Usual and unusual radiographic presentations. Semin Roentgenol 1979;14(3):204-43.

  • 7. Peter Armstrong. Alan G. Wilson, Paul Dee, David M Hansell, Imaging of diseases of the chest (3rd edn). 2000; 191.

PULMONARY ASPERGILLOSIS

PLAIN FILM

Non-invasive (Aspergilloma)

Solid round mass within a thick walled cavity with a crescent shaped air space (Air-meniscus sign) separating fungus ball from cavity wall is characteristic. Pleural thickening of up to 2 cm adjacent to the cavity may be seen. Fungus ball may show rim calcification. An air fluid level may be present within the cavity.

Invasive

The radiographic findings are varied depending upon the stage, severity, and extent of disease. Single or multiple areas of consolidation or disseminated miliary/ nodular pattern may be seen. Areas of consolidation in invasive aspergillosis represent focal infarctions and are typically round with indistinct margins.

ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)

Acute

Bronchial wall thickening and atelectasis, mucoid impaction pattern, or consolidation are ususal. V or Y shaped central mucus plugs with ‘finger in glove’ appearance may be seen in ABPA.

Chronic

Bronchiectasis with scarring/fibrosis (usually upper zone) is more common, mucus plugs no longer evident.

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CT SCAN

Non-invasive (Aspergilloma)

Sponge-like mass containing irregular air spaces which change with patient’s position is characteristic. Air crescent sign and wall of pre-existing cavity are clearly visible.

Invasive

CT halo’ sign is a band of increased attenuation in the surrounding lung. The CT halo’ progresses to the ‘air crescent’ sign which is a lucent crescent of air around the margin. Hilar adenopathy is not a feature. Effusions occur only if hemorrhagic infarction results in bleeding into the pleural space. Chest wall or mediastinal invasion is rare. Peribronchial consolidation or ground-glass opacity, centrilobular micronodules and even bronchiectasis can occur.

ABPA

Characteristic proximal pattern of bronchiectasis predominantly in the upper lobes is seen.

BIBLIOGRAPHY

  • 1. Castagnone D, Radaelli P, Cortelezzi A. Radiological aspects of invasive pulmonary aspergillosis. Radiol Med (Torino) 1984:70(1-2):1-6.

  • 2. Freundlich IM, Israel HL. Pulmonary aspergillosis. Clin Radiol 1973;24(2):248-53.

  • 3. Irwin A. Radiology of Aspergillosis. Clin Radiol 1967;18(4):432-8.

  • 4. Libinski JK, Atkinson EW, Israel HI. Pleural thickening as a manifestation of Aspergillus superinfection. Am J Roentgenol Ther Nucl Med 1974;120(4):883-6.

  • 5. Zizzi G, Melillo L, Cammisa M. Carotenuto M. Invasive pulmonary aspergillosis. Radiol Med Torino 1994;87(4):435-40.

BRONCHIECTASIS

Bronchial wall visible as single or parallel linear opacities (Tram-track), ring and curvilinear opacities (bronchial end-on), may contain air-fluid levels, are seen. Loss of vascular shadows due to adjacent peribronchial fibrosis may be present.

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Bronchiectasis may show over-inflation or atelectasis, or may manifest with associated infectious consolidation, scaring, bullae and pleural thickening. Dilated airways filled with secretions give rise to band shadows of variable size. Band shadow may branch, giving V, Y, or more complex shaped opacities.

BIBLIOGRAPHY

  • 1. Peter Armstrong, Alan G Wilson, Paul Dee, David M Hansell. Imaging of diseases of the chest (3rd edn). 2000; 904.

  • 2. Smith IE, Flower CD. Review article: Imaging in bronchiectasis. Br J Radiol 1996; 69(823): 589-93.

  • 3. Van der Bruggen-Bogaarts BA, van der Bruggen HM, van Waes PF, Lammers JW. Screening for bronchiectasis. A comparative study between chest radiography and high-resolution CT. Chest 1996; 109(3):608-11.

CONSOLIDATION

Consolidation when associated with a patent airway, an air bronchogram is often visible. This sign is produced by the radiographic contrast between the column of air in the airway and surrounding opaque acini. When consolidation is secondary to bronchial obstruction, air in the airways is resorbed and replaced by fluid and the affected area is of uniform density. The volume of purely consolidated lung is similar to that of the normal lung since air is replaced by a similar volume of fluid or solid. Air lucencies within consolidated lung may be due to resolution of the process with intervening normal lung, necrosis of tissue with cavitation or pneumatoceles. When consolidation is due to fluid, its distribution is influenced by gravity, so that in acute pneumonitis consolidation is often denser and more clearly demarcated inferiorly by a pleural surface, and is less dense and more indistinct superiorly. When air bronchograms are evident on the chest radiograph these may manifest as echogenic linear structures. When bronchi become fluid filled they are more clearly demonstrated as echo-free branching structures.

LOBAR CONSOLIDATION

Consolidation of complete lobe produces a homogeneous opacity, possibly containing an air bronchogram, delineated by the chest wall;

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mediastinum, inter lobar fissure or diaphragm and mediastinum adjacent to the non-aerated lung is obscured. Right upper lobe consolidation: This is confined by the horizontal fissure inferiorly and the upper half of the oblique fissure posteriorly, and may obscure the right upper mediastinum. Right middle lobe consolidation: This is limited by the horizontal fissure above and the lower half of the oblique fissure posteriorly, and may obscure the right heart border. • Lower lobe consolidation: This is limited by the oblique fissure anteriorly, and may obscure the diaphragm. Left upper lobe and lingular consolidation: These are limited by the oblique fissure posteriorly. Lingular consolidation lobe may obscure the aortic knuckle.

BIBLIOGRAPHY

  • 1. Reed JC. Chest radiology: Plain film patterns and differential diagnosis (3rd edn). Chicago: Mosby-year Book; 1987.

  • 2. Peter Armstrong. Imaging of diseases of the chest (3rd edn) 2000;77.

  • 3. Robert AN. Squire’s Fundamentals of Radiology (6th edn), London: Harvard University Press; 2004; 112-21.

ATELECTASIS/COLLAPSE

The usual findings are localised increase in lung density, crowding of pulmonary vessels, displacement of fissure/hilum, mediastinal shift, cardiac rotation and approximation of ribs. Compensatory over inflation of normal lung can occur.

BIBLIOGRAPHY

  • 1. Woodring JH, Reed JC. Types and mechanisms of pulmonary atelectasis. J Thorac Imaging 1996;11:92-108.

  • 2. Proto AV, Tocino I. Radiographic manifestations of lobar collapse. Semin Roentgenol 1980;15:117–73.

CAVITATING LESIONS

A cavity is a gas-filled space surrounded by a complete wall which is 3 mm or greater in thickness. Thin walled cavities are called cysts or ring shadows. Cavitations occur when an area of necrosis communicates with a patent airway. Particular features of importance are location of the cavity,

Pulmonology

7

its outline, wall thickness, the presence of fluid level, contents of the cavity, satellite lesions, the appearance of the surrounding lung and multiplicity of lesions. Fluid within a cavity can be demonstrated only when using a horizontal beam. Common cavitating lesions are tuberculosis, staphylococcal infections and carcinoma. The tumor mass itself or the distal lung may cavitate. Tuberculous cavities are usually in the upper zones, in the posterior segments of the upper lobes or apical segments of the lower lobes. The site of lung abscesses following aspiration depends on patient’s position at that time but they are most often right-sided and in the lower zones. Traumatic lung cysts are often sub-pleural. Amebic abscesses are nearly always at the right base, the infection being extended from the liver. Pulmonary infarcts are usually in the lower zone and sequestrated segments are left-sided.

BIBLIOGRAPHY

1. David Sutton. Text book of radiology and imaging. 7th Edition, Churchill Livingstone 2003;1:22-2. 2. Nestor LM, Neil Colman, Paré PD. Diagnosis of Diseases of the Chest(4th edn), Philadelphia: WB Saunders, 1999.

HYDATID CYSTS

PLAIN FILM

One or more spherical or oval well-defined smooth mass of homogeneous density in otherwise normal lung is apparent. Cyst is usually located in middle or lower zone. Multiple cysts are seen in about one-third of patients and are bilateral in 20%. There is a predilection for the lower lobes, the posterior segments, and the right lung. Calcification, which is a common feature of hydatid cysts in the liver, is extremely rare in cysts arising in the lungs. If the cysts ruptures, an air-fluid level is seen. Hydatid cyst may also be present in the pleura, but mediastinal cysts are relatively rare.

  • 8 Atlas of Diagnostic Radiology

CT SCAN

CT scanning reveals fluid contents within the cyst. The daughter cysts when present appear as curved septations. On a CT the cyst wall ranges in thickness from 2 to 1 cm.

BIBLIOGRAPHY

  • 1. Balikian JP, Mudarris FF. Hydatid disease of the lungs: A roentgenologic study of 50 cases. AJR 1974; 122:692-707.

  • 2. Beggs I. The radiology of hydatid disease: A review. AJR 1985; 145:639-48.

PLEURAL EFFUSION

Blunting of posterior than lateral costophrenic angles on upright studies, with meniscus like upper border is usual. Loculated fluid in fissures appear as a spindle shaped pseudotumor. If subpulmonic; apparent diaphragmatic elevation with more lateral appearance to diaphragmatic peak, no lung marking below silhouette of diaphragm, increased distance between ‘diaphragm’ and stomach bubble (>2cm) if on left side is seen. If large mediastinal shift to contralateral side and/or inversion of the ipsilateral hemidiaphragm (more common on left) is present. The radiographic appearance of pleural fluid may be modified when there is associated lung atelectasis. Loculated chest wall effusions tend to be convex to the lung and sharply demarcated on pulmonary aspect when viewed tangentially and are typically greater in length than height.

BIBLIOGRAPHY

  • 1. Amlyn L Evans, Fergus V Gleeson. Radiology in pleural disease: State of the art. Respirology 2004; 9: 300-12.

  • 2. Felson B. Chest roentgenology. Philadelphia: WB Saunders, 1973.

  • 3. Fleischner FG. Atypical arrangement of free pleural effusion. Radiol Clin North Am 1963;1:347-6.

PNEUMOTHORAX

A small pneumothorax in a free pleural space in an erect patient collects at the apex. The lung apex retracts towards the hilum and on a frontal chest film the sharp white line of the visceral pleura will be visible, separated from the chest wall by the radiolucent pleural space, which is devoid of lung markings.

Pulmonology

9

A large pneumothorax may lead to complete retraction of the lung, with some mediastinal shift towards the normal side. Tension pneumothorax may lead to massive displacement of the mediatinum, kinking of the great veins and acute cardiac and respiratory embarrassment. Radiologically the ipsilateral lung may be squashed against the mediastinum, or herniated across the midline, and the ipsilateral hemidiaphragm is depressed. The usual appearance in loculated or encysted pneumothorax is an ovoid air collection adjacent to the chest wall, and it may be radio- graphically indistinguishable from a thin-walled subpleural pulmonary cavity, cyst or bulla. The usual radiological appearance of a hydropneumothorax is that of a pneumothorax containing a horizontal fluid level which separates opaque fluid below from lucent air above.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging. 7th Edition, Churchill Livingstone 2003;1:131.

  • 2. Greene R, McCloud TC, Stark P. Pneumothorax. Seminars in Roentgenolog. 1977;12:313-25.

  • 3. Moskowitz PS, Griscom NT. The medial pneumothorax. Radiolog 1976;120(1): 143-7.

BRONCHOGENIC CARCINOMA

Squamous cell and small cell types of bronchogenic carcinoma tend to present as central tumors, whereas adenocarcinoma and large cell types tend to produce peripheral lesions. Pancoast tumors are frequently squamous cell in type and can resemble pleural thickening in the superior sulcus, usually associated with erosions of adjacent ribs and bones. Peripheral tumors present as solitary nodules with generally well- defined edges; they may be spherical or oval shaped and may be lobulated, approximately 16% show cavitation (usually squamous cell). An irregular edge or ‘corona radiata’ is suggestive but not specific of a malignant tumor. A single band connecting the nodule to pleura (Pleural tail sign) is seen with both malignant and benign lesions. Air broncho- grams are not seen within nodules on plain films (can be seen on thin section CT). The cardinal imaging signs of a central tumor are collapse and consolidation of the lung distal to the tumor and the presence of hilar

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enlargement and‘Golden S’ sign (bulge in fissure adjacent to collapsed segment) indicating central tumor. Visible calcification is virtually never identified on plain chest radiograph but is seen in a small proportion of cases on CT. Doubling of size of tumor is rare in less than one month or more than 18 months. Tumors less than 1cm in size are rarely visible on plain chest radiographs. Alveolar cell carcinomas give rise to alveolar opacities and spread rapidly.

BIBLIOGRAPHY

  • 1. ER Heitzman, B Markarian, BN Raasch, EW Carsky, EJ Lane, ME Berlow. Pathways of tumor spread through the lung; radiologic correlations with anatomy and pathology. Radiology 1982; 144:3-14.

  • 2. Im JG, Choi Bl, Park JH, et al. Case report CT findings of lobar bronchioloalveolar carcinoma. J Computer Assist Tomogr 1986;10:320-2.

  • 3. KS Lee, Y Kim, J Han, EJ Ko, CK Park, SL Primack. Bronchioloalveolar carcinoma: Clinical, histopathologic and radiologic findings. Radiographics 1997; 17:1345-56.

  • 4. Peter Armstrong. Imaging of diseases of the chest (3rd edn) 2000;307.

  • 5. Sider L. Radiographic manifestations of primary bronchogenic carcinoma. Radiol Clinics N Am 1990;28:583-596.

  • 6. Stark P. Multiple independent bronchogenic carcinomas. Radiology 145:599-601,
    1982.

PULMONARY METASTASES

PLAIN FILM

The most common sources of pulmonary metastases include tumors of the breast, colon, kidney, uterus, prostate, head and neck. The hallmark of blood-borne metastases to the lungs on imaging is one or more oval or spherical, discrete pulmonary nodules, usually in the outer portions of the lung. They vary in size, are usually multiple, and have well defined smooth or irregular outlines, with irregular, sometimes frankly nodular thickening of the interstitial pulmonary septa. This finding labeled as the ‘beaded septum sign’ and is regarded as highly specific. Cavitation is most frequent in metastases from tumors of the uterine cervix, colon, and head and neck. Detectable calcification in metastases is very unusual. Miliary nodulation, a pattern of innumerable tiny nodules resembling miliary tuberculosis, is occasionally encountered. Very rarely, metastases present as pulmonary consolidation. This pattern has been seen with melanoma.

Pulmonology

11

Lymphangitis carcinomatosa is usually bilateral. Coarse linear reticular or nodular basal shadowing often with pleural effussion is seen.

CT SCAN

All of the features which can be appreciated on plain X-ray are very obvious on CT scan. In addition, it is possible to show pulmonary vessels leading directly to individual metastases.

BIBLIOGRAPHY

  • 1. Coppage L, Shaw C, Curtis AM. Metastatic disease to the chest in patients with extrathoracic malignanc. J Thorac Imaging. 1987;2:24-37.

  • 2. Davis SD. CT evaluation for pulmonary metastases in patients with extrathoracic malignancy. Radiology 1991; 180(1):1-12.

  • 3. Libshitz HI, North LB: Pulmonary metastases. Radiol Clin North Am.1982; 20(3):437-
    51.

  • 4. Peter Armstrong. Diagnostic Imaging. Fourth Edition. London: Blackwell Science; 1998;96-8.

LYMPHOMA (CHEST)

PLAIN FILM

Cardinal features are mediastinal and hilar lymph node enlargement (more frequent in Hodgkin’s than Non-Hodgkin’s lymphoma (NHL). In Hodgkin’s disease adenopathy tends to be bilateral but asymmetric, involving two or more nodal groups, anterior mediastinal and paratracheal groups are most frequently involved and the posterior mediastinal nodes being infrequently involved. In NHL adenopathy tends to be hilar and mediastinal and is more likely to involve only a single nodal group. Parenchymal involvement is unusual at presentation; it is more common in Hodgkin’s disease and almost always associated with adenopathy. Parenchymal disease alone can occur in 50% of patients with NHL. Parenchymal opacities vary from multiple nodules resembling metastatic disease to air-space consolidations resembling pneumonia, and diffuse interstitial thickening due to lymphatic spread or obstruction. Pleural effusions may ocur which resolve with irradiation of mediastinal nodes. Other manifestations include: Pericardial effusion, chest wall invasion or thymic enlargement but rather rarely.

  • 12 Atlas of Diagnostic Radiology

CT SCAN FINDINGS

CT is the current ‘gold standard’ for evaluating the extent of thoracic involvement in patients with Hodgkin’s disease and, when required, for those with NHL. CT can demonstrate disease even in patients with a normal chest X-ray and is more useful for staging the disease. Compression of the pulmonary arteries, superior vena cava and major bronchi by the enlarged nodes may be seen on a CT chest.

BIBLIOGRAPHY

  • 1. Castellino RA , Blank N, Hoppe RT, C Cho. Hodgkin’s disease contribution of chest CT in initial staging evaluation, Radiology. 1986;160:603-5.

  • 2. David Sutton. Text book of radiology and imaging. 7th Edition, Churchill Livingstone 2003;1:527-59.

  • 3. Marc Bazot, Jacques Cadranel,Sylvie Benayoun, Marc Tassart, Jean Michel Bigot, Marie France Carette. Primary Pulmonary AIDS-Related Lymphoma Radiographic and CT Finding. Chest. 1999;116:1282-6.

  • 4. Ooi GC, Chim CS, Lie AK, Tsang KW. Computed tomography features of primary pulmonary non-Hodgkin’s lymphoma. Clin Radiol 1999; 54:438–43.

  • 5. Romano M, Libshitz HI. Hodgkin disease and non-Hodgkin lymphoma: Plain chest radiographs and chest computed tomography of thoracic involvement in previously untreated patients. Radiol Med (Torino) 1998;95(1-2):49-53.

SARCOIDOSIS

Bilateral hilar adenopathy with paratracheal adenopathy is the classical finding of chest X-ray in sarcoidosis. The degree of hilar node enlargement ranges from barely detectable to massive, eggshell calcification of nodes can be seen specific to sarcoidosis or silicosis. Nodes usually regress with increasing parenchymal involvement. Parenchymal sarcoidosis may manifest as reticulonodular opacities or alveolar opacities. The nodules range from 1 mm to over 5 mm. Alveolar sarcoidosis is due to both filling of air- spaces with inflammatory cells and compression and obliteration of the alveoli by enlarging interstitial nodules. End-stage sarcoidosis typically shows scaring from the hilum into upper and mid zones especially the lower part of the upper lobes. Sarcoidosis is second only to tuberculosis as a predisposing condition for mycetoma formation. Bronchi may be narrowed by external compression or mural granulomata and fibrosis with post-obstruction atelectasis.

BIBLIOGRAPHY

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  • 1. Gross BH, Schneider HJ, Proto AV. Eggshell calcification of lymph nodes: An update, AJR 1980;135: 1265-8.

  • 2. Peter Armstrong. Imaging of diseases of the chest (3rd edn) 2000;641.

  • 3. Rabinowicz JG, Ulreich S, Soriano C. The usual unusual manifestations of sarcoidosis and the ‘hilar haze’- A new diagnostic aid. AJR 1974;120:821-31.

ADULT RESPIRATORY DISTRESS SYNDROME

The radiographic changes may be delayed by 12 hours or more following the onset of clinical symptoms. Bilateral, wide spread, patchy, ill-defined densities resembling cardiogenic pulmonary edema occur usually without cardiomegaly. The densities progress in severity to produce confluent opacification, the distribution of which is variable, but usually all lung zones are involved both centrally and peripherally and air bronchograms may be a prominent feature. CT scans, however, show that the distribution of the pulmonary opacification is patchy. Signs of interstitial edema, like hilar haze and lack of clarity of lung vessel, may also be present.

BIBLIOGRAPHY

  • 1. Joffe N. The adult respiratory distress syndrome. AJR 1974; 122:719-32.

  • 2. Lannuzzi M, Petty TL. The diagnosis, pathogenesis, and treatment of adult respiratory distress syndrome. J Thorac Imaging 1986; 1:1-10.

  • 3. Peter Armstrong. Imaging of diseases of the chest (3rd edn) 2000;450.

CYSTIC FIBROSIS

The pulmonary manifestations are progressive from birth but do not become radiologically apparent for months or years, so X-ray may be completely normal initially. The earliest changes are variable and may include focal atelectasis, recurrent pneumonia, diffuse peribronchial infiltration, emphysema and hilar lymphadenopathy. In the fully developed form of the disease the radiographic findings are remarkably uniform and include the following:

Emphysema, enlarged hilar shadows and increase in perihilar shadows, (reactive hyperplasia to chronic infection), bronchiectasis, either tubular or cystic, and atelectasis and focal infiltration prominent in the upper zones, a reverse of the usual situation with bronchiectasis.

  • 14 Atlas of Diagnostic Radiology

BIBLIOGRAPHY

  • 1. Bradley J Phillips, Charles W Perry. Quick Review: Cystic Fibrosis. The Internet Journal of Internal Medicine 2002;3(1).

  • 2. Don CJ, Dales RE, Desmarias RL, Neimatullah M. The radiographic prevalence of hilar and mediastinal adenopathy in adult cystic fibrosis. Can Assoc Radiol J 1997; 48:265-9.

CRYPTOGENIC FIBROSING ALVEOLITIS

PLAIN FILM

Even symptomatic patients may have a normal chest radiograph initially or may show small opacities which may be nodular or reticulonodular usually in the basal areas. The shadowing is usually symmetric from side-to-side, but atypical distributions can occur. Another common pattern is hazy, ground-glass opacification which may be diffuse or patchy. Volume loss is characterized by diaphragmatic elevation and depression of the fissures. The loss of volume is usually concentrated in the lower lobes but may be generalized. Pneumothorax occurs occasionally, pneumomediastinum is also a recognized complication. With progression of the disease, the initially fine shadowing becomes coarser, and small, cyst like transradiancies appear leading to a honey- comb pattern in one-third to one-half of patients, in later stages of the disease. With gross fibrosis, larger cyst and bullae may appear.

CT SCAN

CT scan is valuable in the diagnosis of early stages of the disease. The earliest CT sign of fibrosing alveolitis is faint subpleural opacification in the posterobasal segments of the lower lobes. As the interstitial fibrosis progresses, a reticular pattern containing small cystic air-spaces becomes evident. Interlobular interstitial thickening manifest as very fine reticulation or areas of ground-glass opacification. Moderately enlarged mediastinal lymph nodes are a frequent finding on CT. Honey comb appearance is very apparent on CT chest.

BIBLIOGRAPHY

  • 1. Armando J Huaringa, Francisco J Leyva. Diffuse Parenchymal Lung Disease: A Practical Approach. The Internet Journal of Pulmonary Medicine 2000;1(1).

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  • 2. Turner-Warwick M, Burrows B, Johnson A. Cryptogenic fibrosing alveolitis: Clinical features and their influence on survival. Thorax 1980; 35: 171-80.

  • 3. Wells A. Clinical usefulness of high resolution computed tomography in cryptogenic fibrosing alveolitis. Thorax 1998; 53(12): 1080-7.

EMPHYSEMA

Chest radiography is insensitive for the detection of mild-to-moderate emphysema. The chest radiographic findings in emphysema may be divided into four types: hyperinflation, vascular change, bullae, and increased markings. Hyperinflation and vascular change are the usual predominant finding, with hyperinflation reflecting functional abnormality and vascular change reflecting lung destruction. Hyperinflation is indicated by a number of signs, e.g low flat diaphragm, increased retrosternal airspace, obtuse costophrenic angle and cardiac diameter less than 11.5 cm, with a vertical heart. Vascular signs include increased transradiancy, reduced size and number of vessels in middle and outer 1/3 of lung indicating prunning of pulmonary arteries due to pulmonary hypertension. Bullae are common and diagnostic in the presence of the above mentioned findings.

BIBLIOGRAPHY

  • 1. Foster WL Jr, Gimenez EI, Roubidoux MA, Sherrier RH, Shannon RH, Roggli VL, et al. The emphysemas: Radiologic–pathologic correlations. Radiographics 1993;13:311–28.

  • 2. Pugatch RD. The radiology of emphysema, Clin Chest Med 1983, 4:433-42.

  • 3. Simon G. Radiology and emphysema. Clin Radiol 1964; 15:293-306.

  • 4. Thurlbeck WM, Simon G. Radiographic appearance of the chest in emphysema. American Journal of Roentgenology 1978;134, 225-32.

LUNG ABSCESS

Lung abscess is seen as an area of lucency within an area of consolidation, may have an air-fluid level. If multiple, consider possibility of septic emboli. Bacterial lung abscess generally form a thick-walled cavity with a shaggy inner lining. The wall may be thick at first, but with further necrosis and coughing up of necrotic material it becomes thinner.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone 2003;(1):138-9.

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Atlas of Diagnostic Radiology

HIATUS HERNIA

Hiatus hernias are frequently incidental findings on chest radiographs and CT. A hiatus hernia appears as a round soft-tissue mass often containing either gas or an air-fluid level behind the heart, usually to the left of the midline in the posterior mediastinum. The larger hernias can also contain small intestine, colon and liver. The diagnosis is readily confirmed by a lateral film, or a barium meal, which shows the stomach above the diaphragm. The diagnosis is also often confirmed by CT which shows the contrast medium-filled stomach above the diaphragm surrounding fatty tissue. With large paraesophageal hernias, the stomach not infrequently undergoes organoaxial rotation and may, therefore contain two air-fluid levels.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn). Churchill Livingstone; 2003;1:75-6.

  • 2. Peter Armstrong. Imaging of diseases of the chest (3rd edn) 2000; 874.

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Pulmonology 17 FIGURE 1.1: Primary Pulmonary Tuberculosis. Tuberculous mediastinal lymphadenopathy. Superior mediastinal widening is seen due

FIGURE 1.1: Primary Pulmonary Tuberculosis. Tuberculous mediastinal lymphadenopathy. Superior mediastinal widening is seen due to tuberculous lymphadenopathy. Inhomogeneous shadowing seen in right upper and mid zones due to tuberculous infiltrates.

Pulmonology 17 FIGURE 1.1: Primary Pulmonary Tuberculosis. Tuberculous mediastinal lymphadenopathy. Superior mediastinal widening is seen due

FIGURE 1.2: Primary Pulmonary Tuberculosis.

Inhomogeneous opacities seen in right upper and mid zones (arrow) with right hilar lymphadenopathy.

  • 18 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.3: Primary Pulmonary Tuberculosis. Nodular opacities seen in the right

FIGURE 1.3: Primary Pulmonary Tuberculosis. Nodular opacities seen in the right upper zone with mediastinal lymphadenopathy on the right side (arrow).

Atlas of Diagnostic Radiology FIGURE 1.3: Primary Pulmonary Tuberculosis. Nodular opacities seen in the right

FIGURE 1.4: Primary Tuberculosis. Patchy infiltration visible in the left mid zone along with widening of the superior mediastinum due to lymphadenopathy.

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Pulmonology 19 FIGURE 1.5: Primary Pulmonary Tuberculosis. Right sided mediastinal lymphadenopathy. FIGURE 1.6: Postprimary Tuberculosis. Bilateral

FIGURE 1.5: Primary Pulmonary Tuberculosis. Right sided mediastinal lymphadenopathy.

Pulmonology 19 FIGURE 1.5: Primary Pulmonary Tuberculosis. Right sided mediastinal lymphadenopathy. FIGURE 1.6: Postprimary Tuberculosis. Bilateral

FIGURE 1.6: Postprimary Tuberculosis. Bilateral tuber- culous infiltration and mediastinal lymphadenopathy.

  • 20 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.7: Postprimary Pulmonary Tuberculosis. Fibrocavitatory lesions in the right upper

FIGURE 1.7: Postprimary Pulmonary Tuberculosis.

Fibrocavitatory lesions in the right upper zone due to

tuberculosis (arrow). Bilateral emphysematous changes with narrow tubular heart shadow.

Atlas of Diagnostic Radiology FIGURE 1.7: Postprimary Pulmonary Tuberculosis. Fibrocavitatory lesions in the right upper

FIGURE 1.8: Miliary Tuberculosis. Right para-tracheal and bilateral hilar lymphadenopathy also seen along with miliary mottling

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Pulmonology 21 FIGURE 1.9: Miliary tuberculosis and left sided pneumothorax (white arrows) and pneumomediastinum (black arrow)

FIGURE 1.9: Miliary tuberculosis and left sided pneumothorax (white arrows) and pneumomediastinum (black arrow) (Pneumothorax rarely seen in miliary tuberculosis).

Pulmonology 21 FIGURE 1.9: Miliary tuberculosis and left sided pneumothorax (white arrows) and pneumomediastinum (black arrow)

FIGURE 1.10: Miliary Tuberculosis. Consolidation of the right lower lobe is also seen due to secondary bacterial infection.

  • 22 Atlas of Diagnostic Radiology

A
A
B
B

FIGURES 1.11A AND B: Miliary Tuberculosis. (A) Miliary mottling more on left side. Hilar and superior mediastinal lymphadenopathy is also apparent. (B) An enlarged view showing miliary mottling.

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Pulmonology 23 FIGURE 1.12: Miliary Tuberculosis. Wide spread nodular shadowing. FIGURE 1.13: Chronic Pulmonary Tuberculosis. Partial

FIGURE 1.12: Miliary Tuberculosis. Wide spread nodular shadowing.

Pulmonology 23 FIGURE 1.12: Miliary Tuberculosis. Wide spread nodular shadowing. FIGURE 1.13: Chronic Pulmonary Tuberculosis. Partial

FIGURE 1.13: Chronic Pulmonary Tuberculosis. Partial consolidation of right upper lobe and a large cavity in left upper zone (arrow) with raised left dome of diaphragm; pleural thickening and calcification.

  • 24 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.14: Chronic Pulmonary Tuberculosis. Fibrocavitatory lesions bilaterally more extensive in

FIGURE 1.14: Chronic Pulmonary Tuberculosis.

Fibrocavitatory lesions bilaterally more extensive in right upper zone. Tenting of right hemidiaphragm. Trachea is pulled to the right side.

Atlas of Diagnostic Radiology FIGURE 1.14: Chronic Pulmonary Tuberculosis. Fibrocavitatory lesions bilaterally more extensive in

FIGURE 1.15: Reactivation Tuberculosis. A case of healed pulmonary tuberculosis apparent from fibrotic changes in both the lungs. Reactivation is visible in the form of a thick walled cavity in the left lung (arrows).

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Pulmonology 25 FIGURE 1.16: Tuberculous cavity with secondary infection in left lung (black arrow). Calcified granuloma

FIGURE 1.16: Tuberculous cavity with secondary infection in left lung (black arrow). Calcified granuloma is also visible in right middle zone (white arrow).

Pulmonology 25 FIGURE 1.16: Tuberculous cavity with secondary infection in left lung (black arrow). Calcified granuloma

FIGURE 1.17: Calcified granuloma (Tuberculomas) in a patient treated for tuberculosis (arrows).

  • 26 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.18: Pulmonary Tuberculosis. Tuberculoma in the right lung (arrow). FIGURE

FIGURE 1.18: Pulmonary Tuberculosis. Tuberculoma in the right lung (arrow).

Atlas of Diagnostic Radiology FIGURE 1.18: Pulmonary Tuberculosis. Tuberculoma in the right lung (arrow). FIGURE

FIGURE 1.19: Tuberculoma. A large well-defined soft tissue mass with some calcifications, in the mid zone on right side (arrow). Relatively smaller nodules seen above it (Biopsy proven tuberculoma).

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Pulmonology 27 FIGURE 1.20: Post-tuberculous fibrosis of right lung with ipsilateral shifting of mediastinum and elevation

FIGURE 1.20: Post-tuberculous fibrosis of right lung with ipsilateral shifting of mediastinum and elevation of right dome of diaphragm. Pleural calcification and calcified lymph nodes at the right hilum.

Pulmonology 27 FIGURE 1.20: Post-tuberculous fibrosis of right lung with ipsilateral shifting of mediastinum and elevation

FIGURE 1.21: Post-tuberculous fibrosis and scar ring (arrow) especially in left upper zone and tenting of left hemi- diaphragm.

  • 28 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.22: Fibrocavitatory tuberculosis of left lung along with lobar pneumonia

FIGURE 1.22: Fibrocavitatory tuberculosis of left lung along with lobar pneumonia right upper lobe due to secondary bacterial infection.

Atlas of Diagnostic Radiology FIGURE 1.22: Fibrocavitatory tuberculosis of left lung along with lobar pneumonia

FIGURE 1.23: Pulmonary Tuberculosis. Bilateral apical fibrosis with punctate calcification secondary to tuberculosis, mediastinal, tracheobronchial and left hilar lymphadeno- pathy.

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Pulmonology 29 FIGURE 1.24: Post-tuberculous Cavitations. Such cavities are a good site for Aspergilloma formation (arrows).

FIGURE 1.24: Post-tuberculous Cavitations. Such cavities are a good site for Aspergilloma formation (arrows).

Pulmonology 29 FIGURE 1.24: Post-tuberculous Cavitations. Such cavities are a good site for Aspergilloma formation (arrows).

FIGURE 1.25: Multi-drug Resistant (MDR) Tuberculosis.

Fibrocavitatory pulmonary tuberculosis of both lungs in a patient with multi-drug resistant tuberculosis. Thick walled cavitatory lesions in the upper and basal segments of right upper lobe (arrows).

  • 30 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.26: Post-tuberculous cavitations with fibrotic changes. FIGURE 1.27: Thick walled

FIGURE 1.26: Post-tuberculous cavitations with fibrotic changes.

Atlas of Diagnostic Radiology FIGURE 1.26: Post-tuberculous cavitations with fibrotic changes. FIGURE 1.27: Thick walled

FIGURE 1.27: Thick walled tuberculous cavitations in the right lung (arrows).

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Pulmonology 31 FIGURE 1.28: Post-tuberculous bands. Band atelectasis in right lower zone (white arrow). Emphysematous changes

FIGURE 1.28: Post-tuberculous bands. Band atelectasis in right lower zone (white arrow). Emphysematous changes also seen in both the lungs. Loculated pneumothorax in right costophrenic angle (black arrow).

Pulmonology 31 FIGURE 1.28: Post-tuberculous bands. Band atelectasis in right lower zone (white arrow). Emphysematous changes

FIGURE 1.29: Post-tubercular pleural calcification. Interlacing pattern of pleural calcification especially on the right side (arrow). Calcified pleural plaques also seen along the right dome of diaphragm.

  • 32 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.30A: Series of chest X-rays of biopsy proven case of

FIGURE 1.30A: Series of chest X-rays of biopsy proven case of tuberculosis:

a) Massive left sided pleural effusion seen with shift of mediastinum to right side. Hilar lymphadenopathy also seen on right side with some calcifica- tions (Fluid analysis showed exudate with predominant lymphocytes but no growth of mycobacteria).

Atlas of Diagnostic Radiology FIGURE 1.30A: Series of chest X-rays of biopsy proven case of

FIGURE 1.30B: Large oval opacity with fuzzy margins seen in the left middle and lower zones over- lapping left border of the heart. Elevated left dome of diaphragm with volume loss seen on the left side because of partial collapse of left lower lobe. Small left sided pleural effusion also seen. A large oval lobulated shadow with internal calcifications seen in right hilar region indicating lymphadenopathy (CT guided biopsy of the mass showed caseating granulomas compatible with tuberculosis).

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Pulmonology 33 FIGURE 1.30C: Marked improvement seen in the form of reduction in the size of

FIGURE 1.30C: Marked improvement seen in the form of reduction in the size of mass on the left side with regression of hilar lymph nodes on right side lung expansion also noted (Clinically patient also had hoarseness of voice due to compression of left recurrent laryngeal nerve, which improved markedly with anti-tubercular drug treatment).

Pulmonology 33 FIGURE 1.30C: Marked improvement seen in the form of reduction in the size of

FIGURE 1.30D: Further improvement noted on this chest X-ray.

  • 34 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.31: Tuberculous Bronchopneumonia. Patchy alveolar opacities seen due to bronchial

FIGURE 1.31: Tuberculous Bronchopneumonia. Patchy alveolar opacities seen due to bronchial spread. Cavitations seen on the left side with left upper lobe consolidation with hilar and pleural calcifications.

Atlas of Diagnostic Radiology FIGURE 1.31: Tuberculous Bronchopneumonia. Patchy alveolar opacities seen due to bronchial

FIGURE 1.32: Bilateral tuberculous bronchopneumonia with loculated pneumothorax on right side (arrows).

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Pulmonology 35 FIGURE 1.33: Tuberculous bronchopneumonia. Widespread patchy opacities with air-bronchogram in the right lung- upper

FIGURE 1.33: Tuberculous bronchopneumonia. Widespread patchy opacities with air-bronchogram in the right lung- upper and middle zones with mediastinal lymphadenopathy (arrow).

Pulmonology 35 FIGURE 1.33: Tuberculous bronchopneumonia. Widespread patchy opacities with air-bronchogram in the right lung- upper

FIGURE 1.34: Tuberculous consolidation-collapse left upper lobe. Thickening of pleura seen in interlobar fissure on the right side (arrow).

  • 36 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.35: Aspergilloma in a tuberculous cavity. Fibrotic changes seen bilaterally

FIGURE 1.35: Aspergilloma in a tuberculous cavity. Fibrotic changes seen bilaterally with a large cavity (left side) containing a dense mass with air-crescent around (arrow).

Atlas of Diagnostic Radiology FIGURE 1.35: Aspergilloma in a tuberculous cavity. Fibrotic changes seen bilaterally

FIGURE 1.36: Aspergilloma in a tuberculous cavity (white arrow). Large thick walled cavity with a rounded opacity inside with a translucent rim around (black arrow)

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Pulmonology 37 FIGURE 1.37: Aspergilloma in a post-tuberculous cavity. Cavity in the left apex with soft

FIGURE 1.37: Aspergilloma in a post-tuberculous cavity. Cavity in the left apex with soft tissue mass inside. Soft tissue density with air crescent around.

Pulmonology 37 FIGURE 1.37: Aspergilloma in a post-tuberculous cavity. Cavity in the left apex with soft

FIGURE 1.38: Aspergilloma. Bilateral post-tuberculous cavities with large

fungus ball seen in one of the cavity surrounded by radiolucent crescent all

around. There is also pleural adhesion lymphadenopathy.

in

the

right lung with right hilar

  • 38 Atlas of Diagnostic Radiology

A
A
B
B
C
C

FIGURES 1.39A TO C: Invasive Broncho-pulmonary Aspergillosis.

Multiple irregular and linear opacities seen bilaterally without any hilar or mediastinal lymphadenopathy.

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Pulmonology 39 FIGURE 1.40A: Early and Late Aspergillosis. Axial CT chest. Nodule on CT with surrounding

FIGURE 1.40A: Early and Late Aspergillosis. Axial CT chest. Nodule on CT with surrounding peripheral ill-defined opacification-so-called “halo” sign in a patient with early aspergillus infection post-bone marrow transplant for lymphoma.

Pulmonology 39 FIGURE 1.40A: Early and Late Aspergillosis. Axial CT chest. Nodule on CT with surrounding

FIGURE 1.40B: Cavitating lesion at the left apex- angioinvasive aspergillus infection in a patient with acute myeloid leukemia who underwent bone marrow transplantation.

  • 40 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.41: Cystic bronchiectasis in right middle and lower zones with

FIGURE 1.41: Cystic bronchiectasis in right middle and lower zones with consolidation. Hyperinflated lung fields and tubular heart also visible due to emphysema.

Atlas of Diagnostic Radiology FIGURE 1.41: Cystic bronchiectasis in right middle and lower zones with

FIGURE 1.42: Bilateral bronchiectasis involving middle and lower zones, more on right side.

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41

Pulmonology 41 FIGURE 1.43: Bronchography (Right Oblique View). Cystic bronchiectasis in right middle lobe and medial

FIGURE 1.43: Bronchography (Right Oblique View). Cystic bronchiectasis in right middle lobe and medial segment of right lower lobe. Contrast seen in right lung airways (arrows).

Pulmonology 41 FIGURE 1.43: Bronchography (Right Oblique View). Cystic bronchiectasis in right middle lobe and medial

FIGURE 1.44: Cystic Bronchiectasis. Multiple lucencies with air fluid levels in middle and lower zones of left lung.

  • 42 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.45: Cystic Bronchiectasis. Honey combing with cystic bronchiectasis in right

FIGURE 1.45: Cystic Bronchiectasis. Honey combing with cystic bronchiectasis in right middle and lower lobes and left lingular and apical basal segments with associated consolidation. Bilateral hilar and right tracheobronchial lymphadenopathy also visible.

Atlas of Diagnostic Radiology FIGURE 1.45: Cystic Bronchiectasis. Honey combing with cystic bronchiectasis in right

FIGURE 1.46: Post-tuberculous Bronchiectasis. CT scan chest axial section (lung window) showing bronchiectasis of apical segment of right lower lobe with pleural thickening.

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43

Pulmonology 43 FIGURE 1.47: CT Chest Axial Section (Lung Window). Bronchectasis. Multiple bronchiectatic cavities right apical

FIGURE 1.47: CT Chest Axial Section (Lung Window).

Bronchectasis. Multiple bronchiectatic cavities right apical and left lingular segments. Pleural thickening of right lung is also seen.

Pulmonology 43 FIGURE 1.47: CT Chest Axial Section (Lung Window). Bronchectasis. Multiple bronchiectatic cavities right apical

FIGURE 1.48: Bronchiectasis with Cor pulmonale. CT scan chest showing bilateral bronchiectasis and cardiomegaly due to cor pulmonale.

Pulmonology 43 FIGURE 1.47: CT Chest Axial Section (Lung Window). Bronchectasis. Multiple bronchiectatic cavities right apical

FIGURE 1.49: Cystic Fibrosis. Thick walled bronchi with bilateral cystic changes and fibrosis.

  • 44 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.50: Cystic Fibrosis. Course and thick bronchial shadows seen in

FIGURE 1.50: Cystic Fibrosis. Course and thick bronchial shadows seen in both lower zones with cystic bronchiectatic changes.

Atlas of Diagnostic Radiology FIGURE 1.50: Cystic Fibrosis. Course and thick bronchial shadows seen in

FIGURE 1.51: Cystic Fibrosis. Bronchiectatic changes, thick walled bronchi, fibrosis and prominent hilar and emphysematous lungs.

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Pulmonology 45 FIGURE 1.52: Staphylococcal pneumonia . Consolidation with partial collapse seen in the left lower

FIGURE 1.52: Staphylococcal pneumonia. Consolidation with partial collapse seen in the left lower zone with elevated left dome of diaphragm. Multiple pneumatoceles seen above consolidation (arrow).

Pulmonology 45 FIGURE 1.52: Staphylococcal pneumonia . Consolidation with partial collapse seen in the left lower

FIGURE 1.53: Mycoplasma pneumonia. Reticulonodular shadowing is seen bilaterally but more clearly marked on the right side.

  • 46 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.54: Right Lower Lobe Pneumonia. Opacity due to consolidation of

FIGURE 1.54: Right Lower Lobe Pneumonia. Opacity due to consolidation of right lower lobe. Right costophrenic angle is obliterated due to pleural effusion. Cardiomegaly is also present due to underlying ischemic heart disease.

Atlas of Diagnostic Radiology FIGURE 1.54: Right Lower Lobe Pneumonia. Opacity due to consolidation of

FIGURE 1.55: Atypical Pneumonia. Bilateral reticulonodular shadowing especially in the right lower zone. Smalll amount of pleural effusion seen on the right side. Air space shadowing right lower lobe and left lower lobe.

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Pulmonology 47 FIGURE 1.56: Consolidation-collapse Right Upper Lobe. Right upper lobe consolidation with partial collapse. Air

FIGURE 1.56: Consolidation-collapse Right Upper Lobe.

Right upper lobe consolidation with partial collapse. Air bronchogram sign is seen. Trachea is central but the interlobar fissure has been pulled up.

Pulmonology 47 FIGURE 1.56: Consolidation-collapse Right Upper Lobe. Right upper lobe consolidation with partial collapse. Air

FIGURE 1.57: Pneumonia Left Lower Lobe. Consolidation of left lower lobe with mild left pleural effusion

  • 48 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.58: Post-pneumonic Pneumatoceles. Multiple cavities in the right middle and

FIGURE 1.58: Post-pneumonic Pneumatoceles. Multiple cavities in the right middle and lower zones.

Atlas of Diagnostic Radiology FIGURE 1.58: Post-pneumonic Pneumatoceles. Multiple cavities in the right middle and

FIGURE 1.59: Pneumonia Right Lower Lobe. Consolidation and collapse of right lower lobe. Loss of translucency over the lower thoracic vertebra obliterating posterior costophrenic angle indicating pleural effusion.

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49

Pulmonology 49 FIGURE 1.60: Left Lower Lobe Pneumonia. Left lower lobe consolidation with partial collapse due

FIGURE 1.60: Left Lower Lobe Pneumonia. Left lower lobe consolidation with partial collapse due to pneumonia.

Pulmonology 49 FIGURE 1.60: Left Lower Lobe Pneumonia. Left lower lobe consolidation with partial collapse due

FIGURE 1.61: Left upper lobe consolidation due to pneumonia.

  • 50 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.62: Pneumonia Left Lower Lobe. Consolidation of left lower lobe

FIGURE 1.62: Pneumonia Left Lower Lobe. Consolidation of left lower lobe with air bronchogram. Emphysematous changes and narrow tubular heart shadow.

Atlas of Diagnostic Radiology FIGURE 1.62: Pneumonia Left Lower Lobe. Consolidation of left lower lobe

FIGURE 1.63: Collapse of left upper lobe, left dome of the diaphragm is elevated along with ipsilateral mediastinal shift. Compensatory emphysema of right lung with herniation to the contralateral side.

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51

Pulmonology 51 FIGURE 1.64: Consolidation of Right Middle Lobe. Homogenous opacity overlying the heart. FIGURE 1.65:

FIGURE 1.64: Consolidation of Right Middle Lobe.

Homogenous opacity overlying the heart.

Pulmonology 51 FIGURE 1.64: Consolidation of Right Middle Lobe. Homogenous opacity overlying the heart. FIGURE 1.65:

FIGURE 1.65: Tubercular Pneumonia Left Upper Lobe.

Consolidation of left upper lobe with air bronchogram. Right lung is hyperinflated with nodular opacities in the apex, also mediastinal widening due to lymphadenopathy.

  • 52 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.66: Legionnaine’s Pneumonia. Cardiomegaly with bilateral inhomogeneous opacities silhouetting both

FIGURE 1.66: Legionnaine’s Pneumonia. Cardiomegaly with bilateral inhomogeneous opacities silhouetting both heart borders. Obliterated right costophrenic angle due to small effusion.

Atlas of Diagnostic Radiology FIGURE 1.66: Legionnaine’s Pneumonia. Cardiomegaly with bilateral inhomogeneous opacities silhouetting both

FIGURE 1.67: Left Lower Lobe Pneumonia. Lingular and lower lobe consolidation. Opacity along the left heart border with elevated diaphragm and reduced lung volume on left side.

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53

Pulmonology 53 FIGURE 1.68: Consolidation of left lower lobe and part of Lingular lobe. Homogenous opacity

FIGURE 1.68: Consolidation of left lower lobe and part of Lingular lobe. Homogenous opacity in left lower zone (arrow), silhouetting left hemi-diaphragm partly with air bronchogram.

Pulmonology 53 FIGURE 1.68: Consolidation of left lower lobe and part of Lingular lobe. Homogenous opacity

FIGURE 1.69: Fibrocavitating lesion in left apex with bilateral honey combing and consolidation of right middle and lower zones as well as left lingular and lower lobe segments. Klebsiella was grown from the sputum. Patient has been a chronic smoker. Heart is enlarged with unfolding of aortic arch.

  • 54 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.70: Segmental consolidation involving the right lower lobe in a

FIGURE 1.70: Segmental consolidation involving the right lower lobe in a patient with COPD.

Atlas of Diagnostic Radiology FIGURE 1.70: Segmental consolidation involving the right lower lobe in a

FIGURE 1.71: Consolidation of the right middle lobe, obliterating the rigth border of the heart but right dome of diaphragm is clearly visible.

Pulmonology

55

Pulmonology 55 FIGURE 1.72: Bronchopneumonia. Showing bilateral inhomogeneous opacities in the lower zones more marked on

FIGURE 1.72: Bronchopneumonia. Showing bilateral inhomogeneous opacities in the lower zones more marked on the right side.

Pulmonology 55 FIGURE 1.72: Bronchopneumonia. Showing bilateral inhomogeneous opacities in the lower zones more marked on

FIGURE 1.73: Bronchopneumonia with right pleural effusion. Patchy opacities in both middle and lower zones with obliteration of right costophrenic angle.

  • 56 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.74: Right Lung Collapse. Opaque right hemithorax with ipsilateral shift

FIGURE 1.74: Right Lung Collapse. Opaque right hemithorax with ipsilateral shift of mediastinum due to complete collapse of right lung.

Atlas of Diagnostic Radiology FIGURE 1.74: Right Lung Collapse. Opaque right hemithorax with ipsilateral shift

FIGURE 1.75: Lingular lobe consolidation.

Pulmonology

57

Pulmonology 57 FIGURE 1.76: Pneumocystis carinii pneumonia in a patient with AIDS. Diffuse inhomogeneous shadowing seen

FIGURE 1.76: Pneumocystis carinii pneumonia in a patient with AIDS. Diffuse inhomogeneous shadowing seen in both lungs.

Pulmonology 57 FIGURE 1.76: Pneumocystis carinii pneumonia in a patient with AIDS. Diffuse inhomogeneous shadowing seen

FIGURE 1.77: Pneumocystis Carinii Pneumonia.

Cardiomegaly, pneumomediastinum and bilateral alveolar infiltrates. The patient was undergoing chemotherapy for acute myeloblastic leukemia.

  • 58 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.78: Pneumocystis carinii infection. Bilateral peri- hilar and ground glass

FIGURE 1.78: Pneumocystis carinii infection. Bilateral peri- hilar and ground glass changes, caused by pneumocystis carinii pneumonia, the most common infectious cause of interstitial lung disease in AIDS patients.

Atlas of Diagnostic Radiology FIGURE 1.78: Pneumocystis carinii infection. Bilateral peri- hilar and ground glass

FIGURE 1.79: CT Axial HRCT image, showing patchy ground glass appearance in the lungs bilaterally in a patient with a pneumocystis carinii pneumonia.

Pulmonology

59

A
A
B
B
C
C
D
D

FIGURES 1.80A TO D: Bronchiolitis Obliterans with Organizing Pneumonia. (A,B) Chest X-rays show bilateral progressively increasing multiple alveolar opacities. (C,D) CT scan shows multiple bilateral alveolar opacities with air bronchogram with distorsion of air spaces and peri-bronchial thickenning.

Pulmonology 59 A B C D FIGURES 1.80A TO D: Bronchiolitis Obliterans with Organizing Pneumonia. (A,B)

FIGURE 1.81: Bilateral Pneumonia. Multiple air space shadows seen bilaterally due to bacterial pneumonia.

  • 60 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.82: Consolidation left lower and lingular lobe due to pneumonia

FIGURE 1.82: Consolidation left lower and lingular lobe due to pneumonia with small pleural effusion.

Atlas of Diagnostic Radiology FIGURE 1.82: Consolidation left lower and lingular lobe due to pneumonia

FIGURE 1.83: Collapse of the left lung caused by carcinoma of the left main bronchus with compensatory emphysema on opposite side.

Pulmonology

61

Pulmonology 61 FIGURE 1.84: Chickenpox. Small calcified opacities seen in both lung fields following a previous

FIGURE 1.84: Chickenpox. Small calcified opacities seen in both lung fields following a previous chickenpox infection.

Pulmonology 61 FIGURE 1.84: Chickenpox. Small calcified opacities seen in both lung fields following a previous

FIGURE 1.85: Consolidation Left Lower Lobe. Left lower lobe consolidation due to pneumonia (air bronchogram sign positive), obliteration of left costophrenic angle and left dome of diaphragm because of parapneumonic effusion is also seen.

  • 62 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.86: Pulmonary Hydatid Cysts. Two large rounded opacities partly over

FIGURE 1.86: Pulmonary Hydatid Cysts. Two large rounded opacities partly over lapping each other seen in the right lung. Anti-echinococcal antibody titers were markedly raised but no evidence of hydatid cyst elsewhere in the body was present.

Atlas of Diagnostic Radiology FIGURE 1.86: Pulmonary Hydatid Cysts. Two large rounded opacities partly over

FIGURE 1.87: Pulmonary Hydatid Cysts. A large hydatid cyst seen in the right lung (upper and middle zones) pressing trachea and superior mediastinum. Patient presented with dysphagia, difficulty in breathing and stridor.

Pulmonology

63

A
A
B
B

FIGURES 1.88A AND B: Infected hydatid cyst left mid and lower zone with pleural reaction seen.

  • 64 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.89: Moderate right sided pleural effusion. Homogeneous opacity with concave

FIGURE 1.89: Moderate right sided pleural effusion. Homogeneous opacity with concave upper margin and obliteration of right costophrenic angle.

Atlas of Diagnostic Radiology FIGURE 1.89: Moderate right sided pleural effusion. Homogeneous opacity with concave

FIGURE 1.90: Right sided pleural effusion, secondary to carcinoma bronchus (Hemorrhagic on aspiration).

Pulmonology

65

Pulmonology 65 FIGURE 1.91: Loculated Tuberculous Empyema. Right sided loculated pleural effusion. Widening of mediastinum due

FIGURE 1.91: Loculated Tuberculous Empyema. Right sided loculated pleural effusion. Widening of mediastinum due to lymphadenopathy.

Pulmonology 65 FIGURE 1.91: Loculated Tuberculous Empyema. Right sided loculated pleural effusion. Widening of mediastinum due

FIGURE 1.92: Moderate left sided pleural effusion with contralateral shift of mediastinum. Left heart order obliterated (silhouette sign) with mediastinal and right hilar lymphadenopathy.

  • 66 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.93: Loculated empyema on right side with fibro- thorax. Large

FIGURE 1.93: Loculated empyema on right side with fibro- thorax. Large opacity in the right lung with sharp medial border and right dense curvilinear band in the middle and lower zones. Mediastinum is central.

Atlas of Diagnostic Radiology FIGURE 1.93: Loculated empyema on right side with fibro- thorax. Large

FIGURE 1.94: Tuberculous Pleural Effusion. Moderate left sided pleural effusion, with right mediastinal shift. Patchy infiltration seen in the middle zone on the right side.

Pulmonology

67

Pulmonology 67 FIGURE 1.95: Non-Hodgkin’s lymphoma with chylothorax. Massive pleural effusion on left side. Right sided

FIGURE 1.95: Non-Hodgkin’s lymphoma with chylothorax. Massive pleural effusion on left side. Right sided hilar and para-tracheal lymphadenopathy. Contralateral shift of mediastinum.

Pulmonology 67 FIGURE 1.95: Non-Hodgkin’s lymphoma with chylothorax. Massive pleural effusion on left side. Right sided

FIGURE 1.96: Massive right sided pleural effusion. Right hemithorax is homogeneously opaque, obliterating costophrenic angle, dome of the diaphragm and cardiac border. No evidence of air- bronchogram. Heart is shifted to the contralateral side.

  • 68 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.97: Malignant pleural effusion in a case of carcinoma bronchus

FIGURE 1.97: Malignant pleural effusion in a case of carcinoma bronchus with lymphangiitic spread in the right upper zone.

Atlas of Diagnostic Radiology FIGURE 1.97: Malignant pleural effusion in a case of carcinoma bronchus

FIGURE 1.98: Tuberculous Pleural Effusion. Dense opacity seen in the left mid and lower zones with concave upper border, obliteration of the left costophrenic angle and left border of the heart. Mediastinum is shifted towards opposite side.

Pulmonology

69

Pulmonology 69 FIGURE 1.99: Tension pneumothorax on the right side with widening of intercostal spaces and

FIGURE 1.99: Tension pneumothorax on the right side with widening of intercostal spaces and depression of right dome of diaphragm. Shifting of mediastinum to the left with collapsed right lung giving ‘Fist sign’ at the right hilum.

Pulmonology 69 FIGURE 1.99: Tension pneumothorax on the right side with widening of intercostal spaces and

FIGURE 1.100: Pockets of pneumothorax with pleural adhesions on the right side. Left upper zone is showing post- tuberculous scarring and fibrosis.

  • 70 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.101: Large hydropneumothorax on the right side. FIGURE 1.102: Moderate

FIGURE 1.101: Large hydropneumothorax on the right side.

Atlas of Diagnostic Radiology FIGURE 1.101: Large hydropneumothorax on the right side. FIGURE 1.102: Moderate

FIGURE 1.102: Moderate pneumothorax with partial collapse of right lung which is also showing bulla in its upper part (arrow). Small pleural effusion on the right side.

Pulmonology

71

Pulmonology 71 FIGURE 1.103: Left sided hydropneumothorax. FIGURE 1.104: Large hydropneumothorax on right side with contralateral

FIGURE 1.103: Left sided hydropneumothorax.

Pulmonology 71 FIGURE 1.103: Left sided hydropneumothorax. FIGURE 1.104: Large hydropneumothorax on right side with contralateral

FIGURE 1.104: Large hydropneumothorax on right side with contralateral mediastinal shift.

  • 72 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.105: Right sided hydropneumothorax with a large bulla seen in

FIGURE 1.105: Right sided hydropneumothorax with a large bulla seen in the partially collapsed right lung (white arrow). Consolidation of the left lower lobe with a thick walled cavity above is also seen. Linear translucency along the heart border bilaterally indicate pneumopericardium/pneumomediastinum (black arrows).

Atlas of Diagnostic Radiology FIGURE 1.105: Right sided hydropneumothorax with a large bulla seen in

FIGURE 1.106: Large right sided hydro (pyo) pneumothorax.

Pulmonology

73

Pulmonology 73 FIGURE 1.107: Hydropneumothorax right side. Patchy opacities in the left lung and right sided

FIGURE 1.107: Hydropneumothorax right side. Patchy opacities in the left lung and right sided hydro- pneumothorax (due to tuberculosis)

Pulmonology 73 FIGURE 1.107: Hydropneumothorax right side. Patchy opacities in the left lung and right sided

FIGURE 1.108: Left sided partial pneumothorax.

  • 74 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.109: Carcinoma bronchus with post-obstructive consolidation in the left upper

FIGURE 1.109: Carcinoma bronchus with post-obstructive consolidation in the left upper lobe. Irregular mass seen at the left hilum.

Atlas of Diagnostic Radiology FIGURE 1.109: Carcinoma bronchus with post-obstructive consolidation in the left upper

FIGURE 1.110: Carcinoma Bronchus. Large oval opacity seen in the right upper lobe. Eccentric cavitation also visible in the upper and lateral part.

Pulmonology

75

Pulmonology 75 FIGURE 1.111: Carcinoma Bronchus. Large inhomo- geneous opacity seen in the right lung. Cavitations

FIGURE 1.111: Carcinoma Bronchus. Large inhomo- geneous opacity seen in the right lung. Cavitations seen within the opacity. Superior mediastinal lymphadenopathy present. Right lower zone is hypertransradiant.

Pulmonology 75 FIGURE 1.111: Carcinoma Bronchus. Large inhomo- geneous opacity seen in the right lung. Cavitations

FIGURE 1.112: Carcinoma bronchus with post-obstructive pneumonia. Non-homogeneous opacity in right upper lobe (anterior and apical segments) sparing the posterior segments. Right hilar and mediastinal lymphadenopathy also present.

  • 76 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.113: Pancoast Tumor. Large well-defined homogeneous opacity occupying whole of

FIGURE 1.113: Pancoast Tumor. Large well-defined homogeneous opacity occupying whole of the right upper and mid zones, obliterating the right mediastinal border and partly right heart border. Elevated right dome of diaphragm due to phrenic nerve palsy is visible. Also right 3rd and 4th ribs show lytic lesions posteriorly.

Atlas of Diagnostic Radiology FIGURE 1.113: Pancoast Tumor. Large well-defined homogeneous opacity occupying whole of

FIGURE 1.114: Carcinoma Bronchus (Squamous Cell Carcinoma).

Mass in the right middle and lower zone with right hilar lymphadenopathy. Right dome of diaphragm in medial 3/4th and right heart border is obliterated (Silhouette sign).

Pulmonology

77

Pulmonology 77 FIGURE 1.115: Carcinoma Bronchus (Squamous Cell Carcinoma). Large mass with irregular and lobulated margins

FIGURE 1.115: Carcinoma Bronchus (Squamous Cell Carcinoma). Large mass with irregular and lobulated margins seen in the left lung.

Pulmonology 77 FIGURE 1.115: Carcinoma Bronchus (Squamous Cell Carcinoma). Large mass with irregular and lobulated margins

FIGURE 1.116: Carcinoma Bronchus. Oval shaped opacity in left upper mid zone with ill-defined margins and erosion of the ribs (arrow).

  • 78 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.117: Carcinoma Bronchus. Irregular mass in the right hilar area

FIGURE 1.117: Carcinoma Bronchus. Irregular mass in the right hilar area with post-obstructive segmental consolidation seen in the right upper and middle zones. Horizontal fissure is prominent because of fluid (Inflammatory) (arrow).

Atlas of Diagnostic Radiology FIGURE 1.117: Carcinoma Bronchus. Irregular mass in the right hilar area

FIGURE 1.118: Pancoast tumor involving the left apex with rib erosions (white arrow). Extensive soft tissue mass (extra pulmonary) with erosion of the medial end of left clavicle (black arrow) is also seen.

Pulmonology

79

Pulmonology 79 FIGURE 1.119: Alveolar Cell Carcinoma. Bilateral ill-defined multiple opacities with pleural effusion on the

FIGURE 1.119: Alveolar Cell Carcinoma. Bilateral ill-defined multiple opacities with pleural effusion on the right side.

Pulmonology 79 FIGURE 1.119: Alveolar Cell Carcinoma. Bilateral ill-defined multiple opacities with pleural effusion on the

FIGURE 1.120: Carcinoma Lung. Soft tissue mass fairly well defined in left upper lobe with central translucencies indicating cavity formation.

  • 80 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.121: Pancoast Tumor. Soft tissue opacity in the right apex

FIGURE 1.121: Pancoast Tumor. Soft tissue opacity in the right apex and supraclavicular region (black arrow) with destruction of 2nd and 3rd ribs (posterior ends) (white arrows).

Atlas of Diagnostic Radiology FIGURE 1.121: Pancoast Tumor. Soft tissue opacity in the right apex

FIGURE 1.122: Carcinoma Bronchus. Cavitating lesion in the left lower zone (black arrow). Left hilar lymphadenopathy (white arrow).

Pulmonology

81

Pulmonology 81 FIGURE 1.123: Carcinoma bronchus with lymphangiitis carcinomatosis and right phrenic nerve palsy. Soft tissue

FIGURE 1.123: Carcinoma bronchus with lymphangiitis carcinomatosis and right phrenic nerve palsy. Soft tissue mass with spiculated margins at right hilum, prominent interstitial markings and raised right hemi-diaphragm.

Pulmonology 81 FIGURE 1.123: Carcinoma bronchus with lymphangiitis carcinomatosis and right phrenic nerve palsy. Soft tissue

FIGURE 1.124: Squamous cell carcinoma with central necrosis. Thick walled cavitatory lesion with air-fluid level (arrow).

  • 82 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.125: Carcinoma Bronchus. An oblong mass with spiculated margins seen

FIGURE 1.125: Carcinoma Bronchus. An oblong mass with spiculated margins seen in the right hilum. Left hilum is also prominent due to lymphadenopathy.

Atlas of Diagnostic Radiology FIGURE 1.125: Carcinoma Bronchus. An oblong mass with spiculated margins seen

FIGURE 1.126: Bronchial Adenoma. Large, well circums- cribed nodule in the right lower zone (arrows). The patient presented with recurrent hemoptysis.

Pulmonology

83

Pulmonology 83 FIGURE 1.127: Carcinoma Bronchus. Large dense opacity wih irregular margins seen in the right

FIGURE 1.127: Carcinoma Bronchus. Large dense opacity wih irregular margins seen in the right hilar region. Right upper lobe is partly consolidated due to post-obtructive infection.

Pulmonology 83 FIGURE 1.127: Carcinoma Bronchus. Large dense opacity wih irregular margins seen in the right

FIGURE 1.128: Carcinoma bronchus with post-obstructive pneumonia. Large mass in the right hilar region with post- obstructive consolidation due to infection in the upper and middle zones.

  • 84 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.129A: Malignant Mesothelioma. Lobulated masses seen in the right hilar

FIGURE 1.129A: Malignant Mesothelioma.

Lobulated masses seen in the right hilar and

peri-hilar regions with widening of superior mediastinum. Moderate pleural effusion is also present.

B
B
C
C

FIGURES 1.129B AND C: CT scan chest showing pleural effusion and a broad based mass arising from pleura on the right side with pleural thickening and pre- tracheal and mediastinal lymphadenopathy.

Pulmonology

85

Pulmonology 85 FIGURE 1.130: Pancoast tumor in right upper lobe with partial collapse. Opacity in right

FIGURE 1.130: Pancoast tumor in right upper lobe with partial collapse. Opacity in right upper zone, inferiorly limited by horizontal fissure which is being pulled up. Destruction of posterior ends of first three ribs.

Pulmonology 85 FIGURE 1.130: Pancoast tumor in right upper lobe with partial collapse. Opacity in right

FIGURE 1.131: Lymphangiitis Carcinomatosa. Disseminated linear and nodular shadowing partly coalescent with each other.

  • 86 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.132: Metastases from carcinoma stomach. Multiple round and oval opacities

FIGURE 1.132: Metastases from carcinoma stomach. Multiple round and oval opacities which are well-defined and of variable sizes.

Atlas of Diagnostic Radiology FIGURE 1.132: Metastases from carcinoma stomach. Multiple round and oval opacities

FIGURE 1.133: Extensive Metastasis from

Osteosarcoma. Multiple large oval, confluent and overlapping dense opacities in both the lung fields and the mediastinum.

Pulmonology

87

Pulmonology 87 FIGURE 1.134: Metastasis from Unknown Primary. Multiple round and oval opacities of variable sizes

FIGURE 1.134: Metastasis from Unknown Primary. Multiple round and oval opacities of variable sizes scattered in both the lung fields. Hilar lymphadenopathy also visible.

Pulmonology 87 FIGURE 1.134: Metastasis from Unknown Primary. Multiple round and oval opacities of variable sizes

FIGURE 1.135: Hamartomas. Two rounded lesions involving the upper and middle zones of right lung with popcorn calcification in the larger lesion.

  • 88 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.136: Metastasis from Carcinoma-Thyroid. Multiple bilateral nodular opacities of different

FIGURE 1.136: Metastasis from Carcinoma-Thyroid. Multiple bilateral nodular opacities of different sizes mainly in the right lung.

Atlas of Diagnostic Radiology FIGURE 1.136: Metastasis from Carcinoma-Thyroid. Multiple bilateral nodular opacities of different

FIGURE 1.137: Metastases from Unknown Primary.

Multiple well-defined masses in the right lung.

Pulmonology

89

Pulmonology 89 FIGURE 1.138: Metastasis from Carcinoma Colon. Multiple opacities of variable sizes especially on right

FIGURE 1.138: Metastasis from Carcinoma Colon. Multiple opacities of variable sizes especially on right side with hilar and superior mediastinal lymphadenopathy.

Pulmonology 89 FIGURE 1.138: Metastasis from Carcinoma Colon. Multiple opacities of variable sizes especially on right

FIGURE 1.139: Metastases with Pleural Effusion. Many well-defined opacities of different sizes seen in the lung. Right hemidiaphragm is elevated due to liver metastases. Right sided pleural effusion also present.

  • 90 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.140: Metastases Secondary to Carcinoma of Breast. Bilateral pleural effusion

FIGURE 1.140: Metastases Secondary to Carcinoma of

Breast. Bilateral pleural effusion with disseminated nodular shadows seen through out both lung fields.

Atlas of Diagnostic Radiology FIGURE 1.140: Metastases Secondary to Carcinoma of Breast. Bilateral pleural effusion

FIGURE 1.141: Neurofibromatosis. Marked scoliosis (concavity facing left) of the spine with a large extrathoracic soft tissue mass on the right side (black arrow). A rounded opacity seen in the right lung (white arrow), is actually due to a neurofibroma present on the posterior chest wall.

Pulmonology

91

Pulmonology 91 FIGURE 1.142: Pleural Fibroma. Large well-defined mass involving the middle and lower zones of

FIGURE 1.142: Pleural Fibroma. Large well-defined mass involving the middle and lower zones of the left lung with marginal calcification.

Pulmonology 91 FIGURE 1.142: Pleural Fibroma. Large well-defined mass involving the middle and lower zones of

FIGURE 1.143: Metastases from Carcinoma Breast. Multiple confluent opacities seen in both the lungs- mid and lower zones with right hilar lymphadenopathy.

  • 92 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.144: Carcinoma Bronchus. CT scan chest showing soft tissue rounded

FIGURE 1.144: Carcinoma Bronchus. CT scan chest showing soft tissue rounded mass in right upper lobe of the lung and pre-tracheal and pre-carinal lymphadenopathy.

A
A
B
B

FIGURES 1.145A AND B: Carcinoma of Bronchus. (A) Chest X-ray showing mild left sided pleural effusion with left hilar lymph nodes enlargement. (B) CT scan done few days later showed collapse of the left lung due to carcinoma of left main bronchus with mild pleural effusion.

Pulmonology A
Pulmonology
A

93

B
B

FIGURES 1.146A AND B: Malignant Mesothelioma.

Mediastinal window showing consolidation with collapse of right lung with pleural effusion and the lung window is showing consolidation and collapse of left lung with pleural effusion, lobulated pleural mass along with hilar and mediastinal lymphadenopathy.

  • 94 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.147: Mesothelioma. IV contrast enhanced CT chest. The image shows

FIGURE 1.147: Mesothelioma. IV contrast enhanced CT chest. The image shows lumpy areas of pleural thickening with mediastinal and right axillary lymphadenopathy in a histologically proven mesothelioma.

Differential diagnosis of multiple round pulmonary opacities

Varying size:

Metastases (GIT, breast, thyroid, kidney) Inflammatory Wegener’s granulomatosis Rheumatoid arthritis AV malformations Infections:

Tuberculosis

Hydatid

Staphylococcus aureus

Histoplasmosis

Size b/w 2-5 mm (typically) Tuberculosis Lymphoma Sarcoidosis Metastases

Size b/w 0.5-2 mm Tuberculosis (Miliary) Sarcoidosis Occupational lung diseases

Pulmonology

95

Pulmonology 95 FIGURE 1.148: Fibrosing Alveolitis. Decrease lung volume, elevated dome of diaphragm with reticulonodular shadowing

FIGURE 1.148: Fibrosing Alveolitis. Decrease lung volume, elevated dome of diaphragm with reticulonodular shadowing seen in the lower lobes.

Pulmonology 95 FIGURE 1.148: Fibrosing Alveolitis. Decrease lung volume, elevated dome of diaphragm with reticulonodular shadowing

FIGURE 1.149: Shrinking lung syndrome in a patient with SLE.

  • 96 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.150: Fibrosing Alveolitis. Bilateral reticulonodular shadowing seen in the lower

FIGURE 1.150: Fibrosing Alveolitis. Bilateral reticulonodular shadowing seen in the lower zones due to interstitial lung disease.

Atlas of Diagnostic Radiology FIGURE 1.150: Fibrosing Alveolitis. Bilateral reticulonodular shadowing seen in the lower

FIGURE 1.151: Fibrosing Alveolitis. Typical honey-coomb appearance seen in a patient with advanced fibrosing alveolitis.

Pulmonology

97

Pulmonology 97 FIGURE 1.152: Chronic extrinsic allergic alveolitis (Bird fanciers lung). Fibrosis and scarring in upper

FIGURE 1.152: Chronic extrinsic allergic alveolitis (Bird fanciers lung). Fibrosis and scarring in upper zones especially on left side. Irregular opacities and some cavitating lesions are also seen.

Pulmonology 97 FIGURE 1.152: Chronic extrinsic allergic alveolitis (Bird fanciers lung). Fibrosis and scarring in upper

FIGURE 1.153: Pneumoconiosis (Siderosis). Dense linear branching opacities seen in both the lung fields more on the left side in a young male who worked for 6 months in ore mines.

  • 98 Atlas of Diagnostic Radiology

A
A
Atlas of Diagnostic Radiology A B FIGURES 1.154A AND B: Silicosis. (A) Chest X-ray showing
B
B

FIGURES 1.154A AND B: Silicosis. (A) Chest X-ray showing bilateral multiple irregular opacities with calcifications, pleural reaction and fibrosis. (B) CT scan chest reveals bilateral hilar lymphadenopathy with calcification. Right soft tissue mass adjacent to right main bronchus, which is speculated. Multiple irregular opacities also seen in both lung fields.

Pulmonology

99

Pulmonology 99 FIGURE 1.155: Acute Respiratory Distress Syndrome. Bilateral air space shadowing in a patient exposed

FIGURE 1.155: Acute Respiratory Distress Syndrome.

Bilateral air space shadowing in a patient exposed to smoke

inhalation.

Pulmonology 99 FIGURE 1.155: Acute Respiratory Distress Syndrome. Bilateral air space shadowing in a patient exposed

FIGURE 1.156: Acute Respiratory Distress Syndrome.

Widespread, uniformly distributed air space shadowing in a septicemic patient with multiorgan faliure.

  • 100 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.157: Eventration of right dome of diaphragm (medial part). FIGURE

FIGURE 1.157: Eventration of right dome of diaphragm (medial part).

Atlas of Diagnostic Radiology FIGURE 1.157: Eventration of right dome of diaphragm (medial part). FIGURE

FIGURE 1.158: Eventration of right dome of diaphragm, mimicking a mass lesion.

Pulmonology

101

Pulmonology 101 FIGURE 1.159: Gross eventration of the left dome of diaphragm FIGURE 1.160: Eventration of

FIGURE 1.159: Gross eventration of the left dome of diaphragm

Pulmonology 101 FIGURE 1.159: Gross eventration of the left dome of diaphragm FIGURE 1.160: Eventration of

FIGURE 1.160: Eventration of right dome of diaphragm giving effect of mass lesion.

  • 102 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.161: Eventration of the right dome of diaphragm FIGURE 1.162:

FIGURE 1.161: Eventration of the right dome of diaphragm

Atlas of Diagnostic Radiology FIGURE 1.161: Eventration of the right dome of diaphragm FIGURE 1.162:

FIGURE 1.162: Guillain Barré Syndrome . Bilateral elevated domes of diaphragm due to involvement of phrenic nerves.

Pulmonology

103

Pulmonology 103 FIGURE 1.163: Chilaiditi’s Syndrome. Chest X-ray of a 21-year old female, mentally retarded, having

FIGURE 1.163: Chilaiditi’s Syndrome. Chest X-ray of a 21-year old female, mentally retarded, having bilateral exophthalmus (congenital) and scoliosis. X-ray reveals bilateral elevated domes of diaphragm with underlying colonic shadows displacing liver, stomach and spleen downwards.

Pulmonology 103 FIGURE 1.163: Chilaiditi’s Syndrome. Chest X-ray of a 21-year old female, mentally retarded, having

FIGURE 1.164: Large Liver Abscess. Markedly elevated right dome of diaphragm due to underlying liver abscess. Minimal right sided pleural effusion also visible.

  • 104 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.165: Large Liver Abscess. Large thick walled cavity with air

FIGURE 1.165: Large Liver Abscess. Large thick walled cavity with air fluid level seen in the right subphrenic region with small pleural effusion and consolidation in the right lower lobe.

Causes of raised diaphragm

Unilateral:

  • - Phrenic nerve palsy

  • - Pulmonary collapse

  • - Pulmonary infarction

  • - Splinting of diaphragm

  • - Eventration

  • - Subphrenic inflammatory disease

  • - Scoliosis

  • - Pleural disease

Bilateral:

  • - Bilateral basal pulmonary collapse

  • - Small lungs

  • - Ascites

  • - Pregnancy

  • - Hepatosplenomegaly

  • - Large intra-abdominal tumor

  • - Bilateral subphrenic abscess

Pulmonology

105

A
A
B
B
C
C
D
D

FIGURES 1.166A TO D: (A) Chest X-ray showing marked elevation of left dome of diaphragm with enormously distended and air filled splenic flexture of the colon due to underlying volvulous. (B to D) Volvulus of large intestine with distension of the proximal colon occupying most of the left hemithorax and causing marked elevation of the left dome of diaphragm with shifting of the mediastinum to opposite side.

  • 106 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.167: Chronic Obstructive Pulmonary Disease. Bilateral emphysematous changes with flattened

FIGURE 1.167: Chronic Obstructive Pulmonary Disease.

Bilateral emphysematous changes with flattened domes of

diaphragm and narrow tubular heart.

Atlas of Diagnostic Radiology FIGURE 1.167: Chronic Obstructive Pulmonary Disease. Bilateral emphysematous changes with flattened

FIGURE 1.168: Acute Asthma. Hyperinflated lungs in a patient with acute severe asthma.

Pulmonology

107

Pulmonology 107 FIGURE 1.169: Emphysematous Bullae. Hyperinflated lung fields, with flattening of domes of diaphragm and

FIGURE 1.169: Emphysematous Bullae. Hyperinflated lung fields, with flattening of domes of diaphragm and narrow tubular heart. Multiple large bullae are visible in the left lung.

Pulmonology 107 FIGURE 1.169: Emphysematous Bullae. Hyperinflated lung fields, with flattening of domes of diaphragm and

FIGURE 1.170: Cor-pulmonale Secondary to COPD.

Cardiomegaly with right ventricular hypertrophy pattern. Central pulmonary artery dilatation with pruning of arteries distally. Hyperinflated lungs with flattening of domes of diaphragm.

  • 108 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.171: Lung Abscess with Effusion. Thick walled cavity with air-fluid

FIGURE 1.171: Lung Abscess with Effusion. Thick walled cavity with air-fluid level seen in the right lower zone. Right costophrenic angle obliterated.

Atlas of Diagnostic Radiology FIGURE 1.171: Lung Abscess with Effusion. Thick walled cavity with air-fluid

FIGURE 1.172: Lung Abscess. Large thick walled cavity with an air-fluid level seen in the left lung.

Pulmonology

109

Pulmonology 109 FIGURE 1.173: Large lung abscess in the left upper lobe with prominent air-fluid level.

FIGURE 1.173: Large lung abscess in the left upper lobe with prominent air-fluid level.

Pulmonology 109 FIGURE 1.173: Large lung abscess in the left upper lobe with prominent air-fluid level.

FIGURE 1.174: Wegener’s Granulomatosis. Bilateral thick walled cavities (arrows) with mediastinal lymphadenopathy and consolidation in the right lower zone.

  • 110 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.175: Post-pneumonic lung abscess seen in the right lower lobe

FIGURE 1.175: Post-pneumonic lung abscess seen in the right lower lobe with small pleural effusion.

Atlas of Diagnostic Radiology FIGURE 1.175: Post-pneumonic lung abscess seen in the right lower lobe

FIGURE 1.176: Wegener’s Granulomatosis. Multiple well-defined nodular opacities seen in the right lung and picture of lobar consolidation in the left lung. Patient had history of non-resolving pneumonia and ultimately cANCA was found to be positive.

Pulmonology

111

Differential diagnosis of cavitatory lung Lesions

 

Neoplastic

-

Carcinoma of bronchus

-

Metastases

-

Hodgkin’s disease

 

Infections

-

Tuberculosis

-

Staphylococcus aureus

 

Inflammatory

-

Wegener’s granulomatosis

-

Rheumatoid nodules

-

Sarcoidosis

 

Vascular

-

Infarction

Abnormal lung:

-

Cystic bronchiectasis

-

Infected emphysematous bulla

Pulmonology 111 Differential diagnosis of cavitatory lung Lesions Neoplastic - Carcinoma of bronchus - Metastases -

FIGURE 1.177: Stage II Sarcoidosis.

Bilateral hilar lymphadenopathy and reticular shadowing in lung fields. Cardiomegaly and aortic calcification (arrow).

Pulmonology 111 Differential diagnosis of cavitatory lung Lesions Neoplastic - Carcinoma of bronchus - Metastases -

FIGURE 1.178: Stage II Sarcoidosis.

Bilateral massive hilar and mediastinal lymphadenopathy with pulmonary infiltrates.

  • 112 Atlas of Diagnostic Radiology

A
A
B
B
C
C

FIGURES 1.179A TO C: Hodgkin’s Lymphoma. (A) Chest X-ray showing a rounded soft tissue mass in the posterior superior mediastinum indenting the trachea from behind. (B, C) CT scan chest of the same patient showing a large mass with an area of central necrosis. The mass is extending upto the vertebral column.

Pulmonology

113

Pulmonology 113 FIGURE 1.180: Histoplasmosis. Asymmetrical bilateral hilar lymphadenopathy with multiple small nodular opacities in the

FIGURE 1.180: Histoplasmosis. Asymmetrical bilateral hilar lymphadenopathy with multiple small nodular opacities in the lung fields.

Pulmonology 113 FIGURE 1.180: Histoplasmosis. Asymmetrical bilateral hilar lymphadenopathy with multiple small nodular opacities in the

FIGURE 1.181: Non-Hodgkin’s Lymphoma. Bilateral asymmetrical superior mediastinal lymphadenopathy.

  • 114 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.182: Non-Hodgkin’s Lymphoma. Mass in superior mediastinum. Elevated right dome

FIGURE 1.182: Non-Hodgkin’s Lymphoma. Mass in superior mediastinum. Elevated right dome of diaphragm. Right tracheobronchial lymphadenopathy with basal atelectasis and small pleural effusion.

Atlas of Diagnostic Radiology FIGURE 1.182: Non-Hodgkin’s Lymphoma. Mass in superior mediastinum. Elevated right dome
Atlas of Diagnostic Radiology FIGURE 1.182: Non-Hodgkin’s Lymphoma. Mass in superior mediastinum. Elevated right dome

FIGURE 1.183: Non-Hodgkin’s Lymphoma. Para-vertebral, low attenuation lobulated mass with destruction of vertebral body and lesion extending up to the spinal cord and displacing it posteriorly.

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115

Pulmonology 115 FIGURE 1.184: Hodgkin’s Disease. Bilateral mediastinal and hilar lymphadenopathy. FIGURE 1.185: Hodgkin’s Disease. Hilar

FIGURE 1.184: Hodgkin’s Disease. Bilateral mediastinal and hilar lymphadenopathy.

Pulmonology 115 FIGURE 1.184: Hodgkin’s Disease. Bilateral mediastinal and hilar lymphadenopathy. FIGURE 1.185: Hodgkin’s Disease. Hilar

FIGURE 1.185: Hodgkin’s Disease. Hilar and mediastinal lymphadenopathy, showing large oval opacity in the right hilar region with widening of mediastinum. Lobulated shadows seen above the arch of aorta on both sides.

  • 116 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.186: Hydatid Cysts. Two large overlapping calcified cystic shadows seen

FIGURE 1.186: Hydatid Cysts. Two large overlapping calcified cystic shadows seen in the anterior and superior mediastinum. Hydatid cysts rarely occur in the mediastinum.

Atlas of Diagnostic Radiology FIGURE 1.186: Hydatid Cysts. Two large overlapping calcified cystic shadows seen

FIGURE 1.187: Dermoid Cyst. Two rounded calcified masses in the anterior mediastinum.

Pulmonology

117

Pulmonology 117 FIGURE 1.188: Bronchogenic Cysts. Three well-defined opacities seen in the retrosternal area (arrows). FIGURE

FIGURE 1.188: Bronchogenic Cysts.

Three well-defined opacities seen in

the retrosternal area (arrows).

Pulmonology 117 FIGURE 1.188: Bronchogenic Cysts. Three well-defined opacities seen in the retrosternal area (arrows). FIGURE

FIGURE 1.189: Thymoma. CT chest showing anterior mediastinal mass due to thymoma in a patient with myesthenia gravis.

Differential diagnosis of mediastinal mass lesions

Anterior mediastinum

-

Lymphadenopathy (TB, lymphoma)

-

Tumors (Thymoma, teratoma, etc.)

-

Goiter

-

Pericardial cyst

-

Morgagnian hernia

Middle

-

Lymphadenopathy

-

Aortic aneurysm

-

Hydatid cyst

-

Carcinoma bronchus

-

Causes of cardiomegaly (in children)

 

Posterior

-

Neuroblastoma (in children)

-

Metastases and myeloma

-

Paraspinal abscess (TB)

-

Hiatus hernia

  • 118 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.190: Retrosternal Goiter. Trachea being compressed and shifted towards right

FIGURE 1.190: Retrosternal Goiter. Trachea being compressed and shifted towards right side (black arrow), widened superior mediastinum (white arrow).

Atlas of Diagnostic Radiology FIGURE 1.190: Retrosternal Goiter. Trachea being compressed and shifted towards right

FIGURE 1.191: Subcutaneous emphysema (arrows) in a patient with acute severe asthma without any pneumothorax.

Pulmonology

119

Pulmonology 119 FIGURE 1.192: Toxic Multinodular Goiter. Punctate calcification seen in the right upper zone due

FIGURE 1.192: Toxic Multinodular Goiter.

Punctate calcification seen in the right upper zone due to calcification in a large toxic multinodular goiter with retrosternal extension (widened superior mediastinum) (arrow).

Pulmonology 119 FIGURE 1.192: Toxic Multinodular Goiter. Punctate calcification seen in the right upper zone due

FIGURE 1.193: Pulmonary translucency comparatively more prominent on left side because of absent breast shadow.

  • 120 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.194: Calcification of tracheal rings; bronchi and costal cartilages in

FIGURE 1.194: Calcification of tracheal rings; bronchi and costal cartilages in an old age patient.

Atlas of Diagnostic Radiology FIGURE 1.194: Calcification of tracheal rings; bronchi and costal cartilages in

FIGURE 1.195: Azygos lobe fissure (black arrow) with azygos vein (white arrow) in the lower margin of fissure.

Pulmonology

121

Pulmonology 121 FIGURE 1.196: Inadvertent aspiration of barium into the lung fields in a patient with

FIGURE 1.196: Inadvertent aspiration of barium into the lung fields in a patient with pharyngeal and vocal cord paralysis. Bilateral nodular opacities more marked in the lower zones (Snowfall appearance).

Pulmonology 121 FIGURE 1.196: Inadvertent aspiration of barium into the lung fields in a patient with

FIGURE 1.197: Pulmonary Embolism. Large infarct seen involving the right lower lobe simulating consolidation, tappering apex towards the right hilum is apparent.

  • 122 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 1.198: Pneumomediastinum (arrows), a chest tube is seen placed in

FIGURE 1.198: Pneumomediastinum (arrows), a chest tube is seen placed in the pericardium from the right side.

Atlas of Diagnostic Radiology FIGURE 1.198: Pneumomediastinum (arrows), a chest tube is seen placed in

FIGURE 1.199: Pulmonary Emboli. CT pulmonary angiogram (CTPA) showing a filling defect in a right lower lobe pulmonary artery consistent with a pulmonary embolus.

Cardiology

123

124
124

Atlas of Diagnostic Radiology

VALVULAR HEART DISEASES

MITRAL STENOSIS

The chest radiograph demonstrates selective left atrial enlargement, which can vary in severity. Left atrial appendage may form a bulge on the left heart border just below the main pulmonary artery making the pulmonary conus prominent. The atrium is large but the left ventricular contour remains small even in late stages. Small aortic knob is seen due to decreased left ventricular output. If the mitral stenosis is both severe and long-standing then calcification of the valve can develop, best visualized in lateral position. Often there is upper lobe blood diversion, with enlargement of the main and central pulmonary arteries indicating pulmonary arterial hypertension. The right-sided cardiac chambers will often be considerably enlarged. ‘Double right heart border’ is present due to considerable enlargement of both atria. Hemosiderosis and pulmonary ossified nodules may occasionally be seen.

BIBLIOGRAPHY

  • 1. Chiles C, Putman CE. Pulmonary and Cardiac Imaging New York: Marcel Dekker.
    1997.

  • 2. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone 2003;1:301-2.

  • 3. Hammer WJ, Roberts WC, DeLeon AC Jr. “Mitral stenosis” secondary to combined “massive” metal annular calcific deposits and small, hypertrophied left ventricles: Hemodynamic documentation in four patients. Am J Med 1978; 64:371.

MITRAL REGURGITATION

In the acute phase, the heart size is likely to remain normal even in the presence of a high left atrial pressure, but acute pulmonary edema can occur. In the chronic phase, the heart tends to enlarge with a left ventricular configuration, left atrial enlargement being proportionately less promi- nent. In long-standing cases, however, there can be marked left atrial enlargement. Calcification of the valve does not occur. The pulmonary vascular appearances are very similar to those of mitral stenosis but the heart size is often larger.

BIBLIOGRAPHY

Cardiology

125

  • 1. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone; 2003;302-3.

  • 2. Higgins CB. Essentials of Cardiac Radiology and Imaging. Philadelphia, Pa: JP Lippincott, 1992.

  • 3. Perloff JK, Roberts WC. The mitral apparatus: Functional anatomy of mitral regurgitation. Circulation 1972; 46:227.

AORTIC STENOSIS

Significant aortic stenosis may present with a virtually normal heart shadow, although it is rare. Initially, concentric left ventricular hyper- trophy produces only some rounding of the cardiac apex (overall heart size is normal), there is also dilatation of the ascending aortic arch. The post-stenotic dilatation of aorta is variable. These appearances can be difficult to detect in the older patient in whom the aorta often becomes unfolded and slightly dilated. On the lateral film, the presence of calcification in the position of the aortic valve is an important sign, usually indicating important valve stenosis. In most cases of aortic stenosis the pulmonary vascularity is normal but in advanced cases there will be left ventricular dysfunction and associated changes of left heart failure.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn). Churchill Livingstone; 2003;1: 381-2.

  • 2. Edwards JE. Calcific aortic stenosis: Pathologic features. Proc. Staff Meet. Mayo Clin 1961; 36:444.

  • 3. Edwards JE. Pathology of acquired valvular disease of the heart. Semin Roentgenol 1979;14:96.

PULMONARY STENOSIS

Initially the heart size is normal. If severe stenosis is present the right ventricular enlargement is visible with an upward turned apex. The main pulmonary artery is often prominent, which is caused by post-stenotic dilatation.Peripheral pulmonary vascularity is usually normal but oligemic lung fields may be seen.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn). Churchill Livingstone; 2003;1: 378-9.

126
126

Atlas of Diagnostic Radiology

CONGENITAL HEART DISEASES

TETRALOGY OF FALLOT’S

Many cases of tetralogy of Fallot have a nearly normal chest film.

In the classical appearance there will be:

1 . Concavity on the left heart border in the region of the hypoplastic main pulmonary artery.

  • 2. Upward prominence of the cardiac apex due to distortion by the large right ventricle.

  • 3. Pulmonary oligemia.

  • 4. In some cases right sided aortic arch.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn). Churchill Livingstone; 2003;1: 382-3.

  • 2. Elliott LP. Cardiac Imaging in Infants, Children and Adults. Philadelphia: JB Lippincott, 1991.

TRANSPOSITION OF THE GREAT ARTERIES

D-loop Transposition

The chest X-ray is often, but not always, characteristic. The heart is slightly enlarged and rounded, generally biventricular enlargement with an oval or egg-shaped configuration. There is pulmonary plethora.

L-loop Transposition

The chest X-ray may show a characteristic long curve to the left heart border due to the abnormal leftward origin of the aorta. A significant proportion of these patients have chest X-rays indistinguishable from normal.

BIBLIOGRAPHY

  • 1. David Sutton. Textbook of radiology and imaging (7th edn), Churchill Livingstone; 2003;1: 385-7.

  • 2. Freedom RM, Mawson JB, Yoo SJ, Benson LN. Congenital Heart Disease; Textbook of Angiocardiography. London; Futura. 1197.

ATRIAL SEPAL DEFECT

The chest X-ray is usually normal if the pulmonary-to-systemic flow ratio is less than 2:1.

Cardiology

127

If ratio exceeds this level there will be pulmonary plethora and cardiac enlargement. The cardiac enlargement is mainly due to right atrial and right ventricular dilatation. In patients with significant pulmonary arterial hypertension (usually the elderly untreated patients), the chest X-ray will show dramatic appearances of central dilated pulmonary arteries and peripheral pulmonary vascular ‘pruning’. Left atrium and left ventricle are normal. Aorta is small.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone; 2003;1: 374.

  • 2. Ronald L. Eisenberg, Clinical Imaging, an atlas of differential diagnosis (4th edn). 2003; 248.

EBSTEIN ANOMALY

The clinical presentation varies considerably, severe cases presenting in infancy with right heart failure and poor forward flow to the pulmonary artery. The chest X-ray in these cases may show massive globular cardio- megaly with pulmonary oligemia. The mildest expression occurs in some adults who present with mild signs or symptoms and a virtually normal chest X-ray.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone; 2003;1: 398.

  • 2. Elliott LP. Cardiac Imaging in Infants, Children and Adults. Philadelphia: JB Lippincott, 1991.

PULMONARY VENOUS HYPERTENSION

The chest X-ray appearances of pulmonary venous hypertension are characterized by:

  • 1. Mild haziness in the lower zones with attenuation of the lower zone vessels.

  • 2. Prominence of the upper zone vessels ‘upper lobe diversion’.

  • 3. The central pulmonary arteries are dilated, tapering to normal caliber as they proceed distally.

  • 128 Atlas of Diagnostic Radiology

    • 5. Chronic changes are associated with Kerley B lines (horizontal subpleural lines, identified at the costophrenic angles).

    • 6. Interstitial edema may cause thickening of the interlobar fissures, seen in the horizontal fissure in the PA film and in both horizontal and oblique fissures in the lateral film.

    • 7. Pulmonary effusions may also develop. The effusion is usually bilateral and can be large in amount.

    • 8. Long-standing pulmonary venous hypertension can occasionally be associated with the development of hemosiderosis (appears as fine punctate calcifications that are scattered throughout both lungs).

    • 9. Pulmonary ossific nodules (small areas of bone formation) can develop if pulmonary hypertension remains severe for a long period of time.

BIBLIOGRAPHY

  • 1. David Sutton. Textbook of radiology and imaging (7th edn), Churchill Livingstone; 2003;1: 288-90.

  • 2. Peter Armstrong, Imaging of diseases of the chest (3rd edn). 2000; 431.

  • 3. Simon M. The pulmonary vessels: Their hemodynamic evaluation using routine radiographs. Radiol Clin North Am 1963; 11:362.

ACUTE MYOCARDIAL INFARCTION

Chest radiography is not the primary method for diagnosing this condition, it is a useful adjunct. It will be normal in the acute phase in the majority of patients. The chest radiograph provides some insight into the severity of the myocardial infarction. The most common feature identified is the development of pulmonary edema. Pleural effusions can develop if the left heart failure is prolonged. Progressive enlargement of the heart can occur, more often in anterior myocardial infarction. Several of the important complications of an acute myocardial infarction can be suggested from the plain chest radiograph. If a left ventricular-aneurysm develops it is revealed as a localised bulge on the left heart border on chest radiograph. The wall of long-standing aneurysm may show calcification.

BIBLIOGRAPHY

  • 1. Chiles C, Putman CE. Pulmonary and Cardiac Imaging New York. Marcel Dekker.
    1997.

  • 2. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone;

Cardiology
Cardiology

CONGESTIVE CARDIAC FAILURE

129
129

The usual signs are cardiomegaly with left ventricular enlargement, and pulmonary venous hypertension signs. Pleural effusion is common (bilateral or right sided; unilateral left sided effusions rare and suggests another cause).

BIBLIOGRAPHY

  • 1. Ronald L Eisenberg. Clinical Imaging, an atlas of differential diagnosis (4th edn). 2003; 238.

DILATED CARDIOMYOPATHY

The plain film is often abnormal, demonstrating cardiac enlargement of all four chambers or of just the left ventricle. In the untreated patient there is often volume overload of the left atrium leading to engorgement of the pulmonary vasculature. The diagnosis cannot be made on the chest radiograph alone.

BIBLIOGRAPHY

  • 1. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone; 2003;1: 299.

PERICARDIAL EFFUSION

The appearances that can be identified on the plain film depend on the amount of fluid present. A very large fluid collection can cause massive enlargement of cardiac shadow. The cardiac shadow has a rounded, globular appearance with no particular chamber enlargement being identified (water bottle cardiac silhouette) and sharp cardiophrenic angles. If large enough the effusion will lead to an obstruction of the venous return to the right heart, which produces clear rather than congested lungs. A rapidly increasing heart size on serial films is seen as effusion accumulates. On lateral view loss of retrosternal space and separation of retrosternal from epicardical fat “fat pad sign” could be seen.

  • 130 Atlas of Diagnostic Radiology

Causes of pericardial effusion

 

Transudative:

Heart failure • Hypoalbuminemia

Uremia

 

Exudative:

Viral infection (pericarditis or myocarditis)

Acute or chronic bacterial infection including tuberculosis

Inflammation (e.g. Dresseler’s syndrome)

Hemopericardium:

• Post-cardiac surgery • Perforation of the heart by catheter (angiogram, pacemaker or angioplasty). • Bleeding disorders (including anticoagulation)

BIBLIOGRAPHY

  • 1. Chiles C, Putman CE. Pulmonary and Cardiac Imaging New York: Marcel Dekker.
    1997.

  • 2. David Sutton. Textbook of radiology and imaging (7th edn). Churchill Livingstone; 2003;1: 305-7.

  • 3. Skorton DJ, Schelbert HR, Wolf G L, Brundage BH. Marcus Cardiac Imaging: A Companion to Brauwald’s Heart Disease. 2nd Edition,Philadelphia; WB Saunders;
    1996.

CONSTRICTIVE PERICARDITIS

The heart is often normal in size but can be enlarged especially in effuso- constrictive form. Straightening of the right heart border and roughening of the cardiac outline as a result of pleuro-pericardial adhesions could be seen. Calcification along the heart border is seen in approximately half of the cases, more clearly visible on lateral view. The lungs are usually clear due to constriction over the right heart, although pleural effusion is not uncommon. CT and MRI are helpful in revealing extent and distribution of pericardial calcification and disease.

BIBLIOGRAPHY

  • 1. Braunwald E, Lorell BH. Percardial disease. In braunwald E (Eds): Heart Disease. A Textbook of Cardiovascular Medicine. Saunders 1984;1470.

  • 2. David Sutton. Text book of radiology and imaging (7th edn), Churchill Livingstone 2003;1:307.

Comment

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131

The purpose of this book is to display mainly plain films and CT. Also other techniques of value in the investigation of cardiac abnormality include:

• Echocardiography • Magnetic resonance imaging • Selective coronary angiography • Radio-isotope studies. The plain films, however, do remain the starting point for all these investigations.

  • 132 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.1: Coarctation of Aorta. Inferior rib notching more on left

FIGURE 2.1: Coarctation of Aorta. Inferior rib notching more on left side. Cardiomegaly with left ventricular prepon- derance.

Atlas of Diagnostic Radiology FIGURE 2.1: Coarctation of Aorta. Inferior rib notching more on left

FIGURE 2.2: Coarctation of Aorta. Notching of the inferior borders of the ribs posteriorly seen (arrows).

Cardiology

133

Cardiology 133 FIGURE 2.3: Coarctation of Aorta. Narrow arch and descending aorta and inferior rib notching

FIGURE 2.3: Coarctation of Aorta. Narrow arch and descending aorta and inferior rib notching due to coarctation. cardiomegaly is also present.

A
A
B
B

FIGURES 2.4A AND B: Coarctation of Aorta. MIP (Maximum intensity projection) oblique sagittal MRI image showing the typical appearance of aortic coarctation with prominent collateralization. CT oblique sagittal reconstruction demonstrating the CT appearances of coarctation with an associated calcified bicuspid aortic valve.

  • 134 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.5: Dextrocardia with scoliosis of the spine. FIGURE 2.6: Dextrocardia

FIGURE 2.5: Dextrocardia with scoliosis of the spine.

Atlas of Diagnostic Radiology FIGURE 2.5: Dextrocardia with scoliosis of the spine. FIGURE 2.6: Dextrocardia

FIGURE 2.6: Dextrocardia with Situs Inversus. Stomach fundus visible under the right side of diaphragm

Cardiology

135

Cardiology 135 FIGURE 2.7: Dextrocardia and Situs Inversus. Dextro- rotation of heart, fundal gas seen on

FIGURE 2.7: Dextrocardia and Situs Inversus. Dextro- rotation of heart, fundal gas seen on right side.

Cardiology 135 FIGURE 2.7: Dextrocardia and Situs Inversus. Dextro- rotation of heart, fundal gas seen on

FIGURE 2.8: Dextrocardia. Axial MRI T1 weighted image showing dextrocardia.

  • 136 Atlas of Diagnostic Radiology

A
A
B
B

FIGURES 2.9A AND B: Right Sided Aorta. (A) The shadow of the ascending aorta and aortic knuckle are clearly visible on the right side of the mediastinum (arrow). The left mediastinal shadow is devoid of aortic knuckle and descending aortic shadow. (B) CT scan chest of the same patient showing complete transposition of the aorta including ascending aorta, arch of aorta and descending aorta to the right side.

Cardiology

137

Cardiology 137 FIGURE 2.10: Transposition of Great Arteries. Narrow mediastinum, pulmonary plethora with borderline cardiomegaly. FIGURE

FIGURE 2.10: Transposition of Great Arteries. Narrow mediastinum, pulmonary plethora with borderline cardiomegaly.

Cardiology 137 FIGURE 2.10: Transposition of Great Arteries. Narrow mediastinum, pulmonary plethora with borderline cardiomegaly. FIGURE

FIGURE 2.11: Atrial Septal Defect (Ostium Secundum Type). Cardiomegaly, prominent pulmonary conus, dilated pulmonary vessels and pulmonary plethora seen.

  • 138 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.12: Severe Mitral Stenosis. Cardiomegaly, dilated pulmonary arteries, prominent pulmonary

FIGURE 2.12: Severe Mitral Stenosis. Cardiomegaly, dilated pulmonary arteries, prominent pulmonary conus, upper lobe diversion of blood vesseles and alveolar opacities (more marked on the right side) due to pulmonary edema seen.

Atlas of Diagnostic Radiology FIGURE 2.12: Severe Mitral Stenosis. Cardiomegaly, dilated pulmonary arteries, prominent pulmonary

FIGURE 2.13: Prosthetic Valves (1) Mitral, (2) Aortic. Sternal sutures are also visible.

Cardiology

139

Cardiology 139 FIGURE 2.14: Severe Aortic Stenosis. Marked cardio- megaly with left ventricular preponderance. Ground glass

FIGURE 2.14: Severe Aortic Stenosis. Marked cardio- megaly with left ventricular preponderance. Ground glass appearance of lung fields due to pulmonary edema. Post- stenotic dilatation of aorta is also seen (arrow).

Cardiology 139 FIGURE 2.14: Severe Aortic Stenosis. Marked cardio- megaly with left ventricular preponderance. Ground glass

FIGURE 2.15: Severe Mitral Stenosis. Cardiomegaly with prominent pulmonary conus, large pulmonary arteries, and upper lobe diversion with double atrial shadow visible.

  • 140 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.16: Pulmonary Stenosis. Cardiomegaly with right ventricular preponderance and upward

FIGURE 2.16: Pulmonary Stenosis. Cardiomegaly with right ventricular preponderance and upward turned apex. Prominent main pulmonary artery with post-stenotic dilatation.

Atlas of Diagnostic Radiology FIGURE 2.16: Pulmonary Stenosis. Cardiomegaly with right ventricular preponderance and upward

FIGURE 2.17: Calcified Mitral Valve. Double atrial shadow, straightening of the left border of the heart. Prominent pulmonary conus and linear calcification seen in the area of mitral valve (arrow).

Cardiology

141

Cardiology 141 FIGURE 2.18: X-ray Barium Swallow (Lateral View). Indentation and displacement of the esophagus due

FIGURE 2.18: X-ray Barium Swallow (Lateral View).

Indentation and displacement of the esophagus due to enlarged left atrium of the heart caused by mitral stenosis (arrows).

Cardiology 141 FIGURE 2.18: X-ray Barium Swallow (Lateral View). Indentation and displacement of the esophagus due

FIGURE 2.19: Ebstein Anomaly. Cardiomegaly with globular heart. Pulmonary oligemia with small pulmonary arteries.

  • 142 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.20: Post-tuberculous fibrothorax and constrictive pericarditis. Encasement of the heart

FIGURE 2.20: Post-tuberculous fibrothorax and constrictive pericarditis. Encasement of the heart in calcified pericardium. Calcified plaques are also visible in the right pleura.

Atlas of Diagnostic Radiology FIGURE 2.20: Post-tuberculous fibrothorax and constrictive pericarditis. Encasement of the heart

FIGURE 2.21: Massive pericardial effusion due to viral pericarditis.

Cardiology

143

Cardiology 143 FIGURE 2.22: Massive pericardial effusion. Sharp margins of the heart shadow and clear lung

FIGURE 2.22: Massive pericardial effusion. Sharp margins of the heart shadow and clear lung fields. Pneumopericardium is also seen, which was iatrogenic (arrow).

Cardiology 143 FIGURE 2.22: Massive pericardial effusion. Sharp margins of the heart shadow and clear lung

FIGURE 2.23: Constrictive Pericarditis. Linear rim of pericardial calcification visible along anterior wall and apex of the heart (arrow).

  • 144 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.24: Effusoconstrictive pericarditis due to tuberculosis, Linear pericardial calcification are

FIGURE 2.24: Effusoconstrictive pericarditis due to tuberculosis, Linear pericardial calcification are visible along the left border of the heart (arrow). Post-tuberculous scaring also visible in right upper zone.

Atlas of Diagnostic Radiology FIGURE 2.24: Effusoconstrictive pericarditis due to tuberculosis, Linear pericardial calcification are
Atlas of Diagnostic Radiology FIGURE 2.24: Effusoconstrictive pericarditis due to tuberculosis, Linear pericardial calcification are

FIGURE 2.25: MRI of a patient with constrictive pericarditis, showing thickened pericardium and minimal pericardial effusion, low signal on T-1 and high on T-2 images.

Cardiology

145

Cardiology 145 FIGURE 2.26: Acute pulmonary edema due to left ventricular failure following acute myocardial infarction.

FIGURE 2.26: Acute pulmonary edema due to left ventricular failure following acute myocardial infarction.

Cardiology 145 FIGURE 2.26: Acute pulmonary edema due to left ventricular failure following acute myocardial infarction.

FIGURE 2.27: Cor-pulmonale Secondary to COPD.

Cardiomegaly with right ventricular hypertrophy pattern. Central pulmonary artery dilatation with pruning of arteries distally. Hyperinflated lungs with flattening of domes of diaphragm.

  • 146 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.28: Congestive Cardiac Failure. Cardiomegaly with pulmonary plethora and right

FIGURE 2.28: Congestive Cardiac Failure. Cardiomegaly with pulmonary plethora and right sided pleural effusion.

Atlas of Diagnostic Radiology FIGURE 2.28: Congestive Cardiac Failure. Cardiomegaly with pulmonary plethora and right

FIGURE 2.29: Acute pulmonary edema due to left ventricular failure giving bat’s wings appearance.

Cardiology

147

Cardiology 147 FIGURE 2.30: Dilated Cardiomyopathy. Cardiomegaly with pulmonary plethora. Fluid is seen in transverse fissure

FIGURE 2.30: Dilated Cardiomyopathy. Cardiomegaly with pulmonary plethora. Fluid is seen in transverse fissure (arrow).

Causes of gross cardiac enlargement

  • - Multiple valvular disease Aortic, mitral valve (particularly with regurgitation)

  • - Pericardial effusion

  • - Atrial septal defect (with Eisenmenger’s syndrome)

  • - Cardiomyopathy

  • - Ebstein’s anomaly

  • 148 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.31: Dissecting Aneurysm of Aorta. Aneurysm of the arch and

FIGURE 2.31: Dissecting Aneurysm of Aorta. Aneurysm of the arch and descending aorta (in a young patient) is seen. Associated conditions include Marfan’s and other connective tissue disorders.

Atlas of Diagnostic Radiology FIGURE 2.31: Dissecting Aneurysm of Aorta. Aneurysm of the arch and

FIGURE 2.32: Dissecting Aneurysm. Aneurysm has further progressed as compared to previous X-ray.

Cardiology A
Cardiology
A

149

B
B

FIGURES 2.33A AND B: (A) Aortic aneurysm causing widening of superior mediastinum (PA view). (B) compressing the esophagus (lateral view). The patient presented with dysphagia.

  • 150 Atlas of Diagnostic Radiology

A
A
B
B

FIGURES 2.34A AND B: Aortic Aneurysm. Enlargement of aortic arch almost reaching upto the anterior chest wall showing calcification within it.

Cardiology

151

Cardiology 151 FIGURE 2.35: Aneurysm of the ascending aorta seen as a large rounded opacity in

FIGURE 2.35: Aneurysm of the ascending aorta seen as a large rounded opacity in the right hilar region with widening of mediastinum.

Cardiology 151 FIGURE 2.35: Aneurysm of the ascending aorta seen as a large rounded opacity in

FIGURE 2.36: Left ventricular aneurysm following acute myocardial infarction.

  • 152 Atlas of Diagnostic Radiology

A
A
Atlas of Diagnostic Radiology A B C FIGURES 2.37A TO C: Aortic Dissection. Aneurysmal dilatation
B C
B
C

FIGURES 2.37A TO C: Aortic Dissection. Aneurysmal dilatation of the ascending aorta seen. Tortuousity and unfolding of aorta causing mediastinal widening

also seen.

Atlas of Diagnostic Radiology A B C FIGURES 2.37A TO C: Aortic Dissection. Aneurysmal dilatation

FIGURE 2.38: Left Ventricular

Aneurysm. Coronal CT image with a calcified left ventricular aneurysm.

Cardiology A
Cardiology
A
B
B
Cardiology A B 153 C FIGURES 2.39A TO C: Mediastinal and pericardial lipomatosis in an asthmatic

153

C
C

FIGURES 2.39A TO C: Mediastinal and pericardial lipomatosis in an asthmatic patient with itrogenic Cushing’s syndrome. (A) Chest X-ray shows cardiomegaly with obliteration of cardiophrenic angles bilaterally and smooth mediastinal widening. (B,C) CT chest shows fat deposition around the heart and the mediastinum can be easily distinguished from the anatomical structures.

  • 154 Atlas of Diagnostic Radiology

Atlas of Diagnostic Radiology FIGURE 2.40: Pneumopyopericardium. Massive cardiomegaly with air-fluid level seen within the

FIGURE 2.40: Pneumopyopericardium. Massive cardiomegaly with air-fluid level seen within the pericardium bilaterally (arrows).

A
A
Atlas of Diagnostic Radiology FIGURE 2.40: Pneumopyopericardium. Massive cardiomegaly with air-fluid level seen within the
B
B

FIGURES 2.41A AND B: SVC Stent. (A) PA chest radiograph. There is an SVC stent in situ (arrow) with a soft tissue mediastinal mass. (B) Axial and coronal reconstruction CT images showing the stent in place with no evidence of flow within it and extensive enhancing chest wall collaterals in keeping with recurring SVC obstruction syndrome. The patient was known to have a primary bronchogenic carcinoma.

Cardiology

155

Cardiology 155 FIGURE 2.42: Artificial pacemaker (Unipolar type) with collapse-consolidation of left lung. FIGURE 2.43: Single

FIGURE 2.42: Artificial pacemaker (Unipolar type) with collapse-consolidation of left lung.

Cardiology 155 FIGURE 2.42: Artificial pacemaker (Unipolar type) with collapse-consolidation of left lung. FIGURE 2.43: Single

FIGURE 2.43: Single chamber ventricular pacemaker. PA chest radiograph with a single chamber ventricular pacemaker in situ , the tip of the lead is normally projected to the left of the spine.

Barium Studies and Oral Cholecystography

157

158
158

Atlas of Diagnostic Radiology

REFLUX ESOPHAGITIS

The earliest changes of esophagitis are seen on endoscopy. It is only with more pronounced edema that the earliest change of a fine mucosal nodularity is seen on a double contrast barium swallow. The collapsed esophagus show thickened longitudinal folds, which when nodular, can give an appearance similar to that seen with varices. Multiple fine ulcers give the mucosa a punctate or granular appearance or larger discrete punched out ulcers develops. Scaring produce permanent folds that radiate from the margins of ulcer. Severe scarring results in stricture formation which are usually smooth and long.

BIBLIOGRAPHY

  • 1. Detection of reflux esophagitis on double-contrast esophagrams and endoscopy using the histologic findings as the gold standard. Abdom Imaging 2004;29(4). 421-5.

  • 2. Marsot-Dupuch K, Meyer B, Tiret E, Tubiana JM. Barium imaging of the esophagus. Normal and pathologic aspects. Ann Radiol 1994;37(7-8):457-70.

ACHALASIA

Achalasia is a motor disorder of the esophagus and is caused by degeneration of neurons of Auerbach’s plexus. A barium swallow will show the gastroesophageal junction failing to open fully and tapering to a ‘rat tail’ or ‘bird beak’ appearance. Intact mucosal folds can be traced through this narrowed segment. With time, the esophagus dilates, lengthens and becomes tortuous. When investigating achalasia by barium meal it is not always possible to exclude gastric carcinoma as a cause.

BIBLIOGRAPHY

  • 1. Kostic SV, Rice TW, Baker ME, et al. Timed barium esophagogram: A simple physiologic assessment for achalasia. J Thorac Cardiovasc Surg 2000; 120(5): 935-
    43.

  • 2. Radiographic evaluation of esophageal function. Gastrointest Endosc Clin N Am 2005; 15(2):231-42.

  • 3. Sezgin O, Ulker A, Temucin G. Barium findings in achalasia. J Clin Rad 2001; 29(1): 31-40.

Barium Studies and Oral Cholecystography

CARCINOMA ESOPHAGUS

159
159

Early esophageal cancer on barium studies appear as depressed, polypoid or plaque-like lesions. In advanced esophageal carcinoma, barium radiology most frequently shows a stricture with an irregular lumen and rolled margins, unlike benign peptic strictures which have a smooth lumen and tapered margins. Some tumors show pronounced ulceration, or are predominantly polypoid or spread submucosally; producing thick and irregular esophageal folds.

BIBLIOGRAPHY

  • 1. Montesi A, Pesaresi A, Graziani L, Salmistraro D, Dini L, Bearzi I. Barium imaging of the esophagus. Normal and pathologic aspects. Ann Radiol 1994;37(7-8):457-70.

  • 2. Nahum H, Reysseguier JC, Prandi D, Conte-Marti J, Benasse S, Lortat-Jacob JL. Tumors of the esophagus. A radiological study of 11 cases. Ann Radiol (Paris) 1972;15(7):581-90.

BEZOARS

A bezoar is a mass of ingested material built up in the stomach, mostly due to matted hair (trichobezoar) or vegetable or fruit pith (phytobezoar), including chewed beetle nuts. Barium outlines and often penetrates the mass, which often appear as a filling defect with a mottled appearance.

BIBLIOGRAPHY

  • 1. Gastric trichobezoar: Barium findings. Radiology 1986;161(1):123-4.

  • 2. Small bowel phytobezoars: Detection with radiography. Radiology 1989;172(3): 705-7.

CARCINOMA STOMACH

Early carcinomas of the stomach may appear as slight elevation or slight depression in the form of an ulcer. In advance carcinoma “meniscus sign” is produced by the margin of the ulcer. Infiltration of the whole of stomach is known as “leather bottle” or “Linitis plastica” appearance. Carcinoma may protrude into the stomach lumen and be polypoid or fungating or may ulcerate or infiltrate. Some Adenocarcinoma produce an excess of extra-cellular mucin, and such mucin–producing carcinomas may show stippled calcification.

  • 160 Atlas of Diagnostic Radiology

BIBLIOGRAPHY

  • 1. Nishimata H, Maruyama M, Shimaoka S, Nishimata Y, Ohi H, Niihara T, et al. Early gastric carcinomas in the cardiac region: Diagnosis with double-contrast X- ray studies. Abdom Imaging. 2003; 28(4):486-91.

  • 2. Ukrisana P, Wangwinyuvirat M. Evaluation of the sensitivity of the double-contrast upper gastrointestinal series in the diagnosis of gastric cancer. J Med Assoc Thai. 2004; 87(1):80-6.

INTESTINAL TUBERCULOSIS

Ileocecal involvement is seen in 80-90% of patients with gastrointestinal tuberculosis. This feature is attributed to the abundance of lymphoid tissue (Peyer’s patches) in the distal and terminal ileum. Early changes on barium examinations reveal nodular thickening of mucosal folds with loss of symmetry in the fold pattern. Similar to Crohn’s disease, deep fissures, sinus tracts, enterocutaneous fistulae, and perforation can occur, although less commonly. A cobblestone appearance of the mucosa is a feature of Crohn’s disease rather than Tuberculosis. Ulceration may be demonstrated on double-contrast examinations, typically perpendicular to the long axis of the bowel; these heal with the formation of short annular strictures. The ileocecal angle is obliterated with a widely patent ileocecal valve. Colonic involvement is characterized by a combination of narrowings, deep ulcerations, and mucosal granulation producing nodularity and inflammatory polyps. Less common findings are aphthous ulcers and a diffuse colitis. Changes are usually noted in the cecum, ascending and transverse colon. Bowel contour may be lost with asymmetry simulating Crohn’s disease. When a short segment is involved, the strictures are hour-glass shaped rather than the apple- core deformity associated with carcinoma. In some cases, they may be indistinguishable.

BIBLIOGRAPHY

  • 1. Gupta SK, Jain AK, Gupta JP, et al. Duodenal tuberculosis. Clin Radiol 1988; 39(2): 159-61.

  • 2. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol 1993; 88(7): 989-99.

  • 3. Segal I, Tim LO, Mirwis J. Pitfalls in the diagnosis of gastrointestinal tuberculosis. Am J Gastroenterol 1981; 75(1): 30-5.

Barium Studies and Oral Cholecystography

MALABSORPTION

161
161

Barium studies of the small intestine can reveal the typical abnormalities forming the malabsorption pattern and include bowel dilatation, mucosal thickening, flocculations, segmentation and bowel dilution of barium in advance cases. These patterns are mostly seen in small intestinal mucosal disorders, but otherwise barium studies can absolutely be normal in conditions like pancreatic insufficiency, post-gastrectomy stae, etc.

BIBLIOGRAPHY

  • 1. Peter Armstrong. Diagnostic Imaging (4th edn). London: Blackwell Science. 1998;173-74.

COELIAC DISEASE

Coeliac disease reflects hypersensitivity to the gliadin fractions of the gluten (found in wheat, barley and rye). The classical radiological feature is ‘jejunization’. Jejunal folds are either widely separated or absent altogether and this feature is accompanied by a paradoxical increase in ileal folds. Unfortunately these classical features are often absent, and probably the commonest feature is luminal dilatation. Transient painless intussusception is common and may be seen during follow-through.

BIBLIOGRAPHY

  • 1. La Seta F, Buccellato A, Albanese M, Barbiera F, Cottone M, Oliva L, et al. Radiology and adult celiac disease. Current indications of small bowel barium examinations. Radiol Med (Torino). 2004;108(5-6):515-21.

  • 2. La Seta F, Salerno G, Buccellato A, Tine F, Furnari G. Radiographic indicants of adult celiac disease assessed by double-contrast small bowel enteroclysis. Eur J Radiol 1992;15(2):157-62.

  • 3. Burrows FG, Toye DK. Coeliac disease. Barium studies. Clin Gastroenterol 1974;3(1):91-107.

WORM INFESTATION

Ascaris lumbricoides appearance on contrast studies is characteristic once the worms have swallowed barium it is seen within their intestinal tract and worms appear as long narrow tubular defects.

  • 162 Atlas of Diagnostic Radiology

Hookworm, Tapeworm, Strongyloides and Anisakis all parasite the small bowel, eliciting non-specific findings of fold thickening, nodularity, mild dilatation and flocculation on contrast studies.

BIBLIOGRAPHY

  • 1. Reeder MM, Palmer PES. Radiology of Tropical Diseases. Baltimore, Williams and Wilkins Company. 1981;411-38.

  • 2. Reeder MM. The radiological evaluation of Ascariasis of gastrointestinal, biliary and respiratory tracts. Semin Roentgenol 1998;33(1):57-78.

ULCERATIVE COLITIS

Double contrast barium enema is more accurate than the single contrast study in revealing early disease and also to show the disease extent and severity, but it cannot visualize alterations in mucosal vascular pattern. There is inflammation and ulceration of the colon, the later being the cardinal radiological sign. The ulcers are usually widespread and shallow. There is loss of normal colonic haustra ‘Bamboo Colon’ in the affected portions. Pseudopolyps can be seen in advance cases as projections into the lumen of the bowel between the ulcers. Strictures are rare and usually indicate malignant transformation. Involvement of the whole colon results in dilatation of the terminal ileum and incompetence of the ileo-caecal valve. Any barium examination is absolutely contraindicated if there is evidence of toxic dilatation or when there is risk of perforation.

BIBLIOGRAPHY

  • 1. Carucci LR, Levine MS. Radiographic imaging of inflammatory bowel disease. Gastroenterol Clin North Am 2002; 31(1): 93-117.