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Master Radiology Notes Chest PDF
Master Radiology Notes Chest PDF
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Normal Chest
Oblique views : retrocardiac area, post. costophernic angles & chest walls.
AP view : ribs are projected over different areas of lung from those of PA + post chest
wall is shown.
Appicogram: A.Apical view : Pt leans back, AP projection & tube angled 50-60
upward (projection of clavicles up).
B.Lordotic view : PA view, Pt leans back, (project clavicles,also done in
cases of middle lobe collapse.
Paired :Insp. & exp. film.
1. Demonstrates air trapping
2. Diaphragm movement.
3. Small pneumothorax.
4. Interstitial shadowing.
Penetrated film :
1. To show the hidden areas.
2. Demonstration of rib destruction.
3. Cavitation or calcification.
4. Air bronchogram demonstration.
* Ant junctioned line: is where the lungs meet anterior to the ascending aorta. It is only 1 mm thick
(from below suprasternal notch).
* Post junctional line : is where the lungs meet posteriorly behind the esophagus. It is 2mm thick
(from
lung apex to level of knuckle).
* Thymus : both borders may be wavy (sign of Mulvey) dt costal cartilage indentation. It is sail
shaped, right border more straight male >female.
* Main fissures : (tangential x-ray beam)
1. PA : horizontal fissure runs from hilum to 6th rib in axillary lines may be slight down curve.
2. Lat : All fissures : oblique fissures commence post from D4 or D5 passing through ! hilum, !
left is steeper & finishes 5cm behind ! ant costophrenic angle.
* Accessory fissures :
1. Azygous fissure : comma shaped, base & nearly always rt sided (failed azygous v. to
migrate). Left side hemiazygous vein.
2. Superior accessory fissure : separates !apical from basal segments of lower lobes.
3. Inferior accessory fissure : separates ! medial basal from the other basal segments (from
cardio
phrenic angle).
4. Left sided horizontal fissure : separates lingula from other upper lobe segments.
Hidden areas :
1. Apices: appicogram.
2. Mediastinum and Hila: lateral film (for central lesions).
3. Diaphragms: post.& lat. basal segments of lower lobes & ! post. sulcus are partially observed.
4. Bones: AP, expiratory film & obliques - Tomography.
6. Lung fields :
Hidden areas :(apices, diaphragm, mediastinum, hilae and bones).
7. Hilum :
Shape, position, density :
-Normally the left hilum is 1/2-1cm higher than right (because left pulm.a. lies above
the left main bronchus before passing post.)
-They should be of equal density and size with concave lateral borders.
-Only the pulmonary arteries and upper lobe veins significantly contribute to hilar
Chest radiology 4
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shadows.
-The maximum diameter of normal descending branch of the right pulmonary
artery is 10-16mm in males, and 9-15mm in females.
-In erect position, the lower lobe vessels are larger than the upper lobe vessels as
the perfusion and areation of the upper zones are reduced.
-The pulmonary arteries accompanying the bronchi, while the veins :
a. Have fewer branches.
b. Less defined and larger.
c. Do not follow the bronchi.( They follow (drain via) interlobular septa)
* Upper lobe bronchus may appear as a ring shadow adjacent to upper outer hilum.
Lymph nodes :
* Intrapulmn lymphatics drain to bronchopulmn node (1st group involved by spread from a periph.
tumor).
* Mediastinal Lns (may be involved by tumors above or below the diaphragm).
1. Ant. mediastinal nodes: (drain thymus & Rt heart - in region of aortic arch.).
2. Intrapulmn. nodes : along main bronchi.
3. Middle mediastinal nodes (lung, bronchi, lt ht, lower trachea & visceral pleura)
a. Bronchopulmn (hilar), drain into.
b. Carinal
c. Tracheo bronchial (Rt - adjacent to azygous , Lt - near RLN).
d. Paratracheal
4. Post mediastinal nodes : drain post diaphragm & lower oesophag. lie around lower descending
aorta & lower oesoph.
5. Parietal nodes: (ant & post behind sternum) ,drain soft tissue & parietal pleura (also intercostal
region).
8. Bronchial vessels :
-Normally not visualized on film.
-The arteries arise from ventral surface of the descending aorta at the level T5-T6.
-Enlarged bronchial arteries, appear as multiple small nodules around hilum.
Cause of enlargement :
* General (congestive cyanotic heart disease).
* Local (bronchiectasis, primary carcinoma).
Chest radiology 5
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Differential Diagnosis
Krley’s Lines :
1. A-lines : Thin, non branching lines radiating from the hilum (2-5cm in length,
thick deep intercommunicating lymphatics, DD: blood vessels).
2. B-lines : -Transverse, thin line of 1-3cm.
-Seen at the base of the lung lying perpendicular to ! pleura (in costo-
phrenic angle).
-Formed by thickened interlobular septa (in lat film seen behind !
sternum () = D lines.
3. C-lines : A spider’s web appearance : interlacing lymphatics.
Silhouette Sign :
-It permits localization of the lesion on the PA view by studying the mediastinal and
diaphragmatic outlines.
-These outlines are visualized because the adjacent alveoli are aerated.
-If air is displaced, the adjacent borders are obliterated where the lesion is located,
conversely if the border is retained and the abnormality is superimposed, the lesion
must be either anterior or posterior e.g.:
* Lesions of the middle lobe (rt) and lingula (lt) affect the right and left
cardiac border.
* Obliteration of the aortic knuckle is a feature of disease in apico-posterior
Chest radiology 7
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Air bronchogram :
An important sign. The bronchus if air filled and not fluid filled becomes visible,
when air is displaced from the surrounding alveoli (parenchyma).
*Causes :
1. Consolidation (Pneumonia, infarction, collapse, Pulm hge, TB).
2. Pulmonary edema.
3. H.M.D = Hyaline membrane disease.
4. Lymphona.
5. Alveolar cell carcinoma.
6. Sarcoidosis.
7. Adult respiratory distress syndrome.
N.B:
* An air bronchogram does not occur within pleural fluid or solid tumor.
* It may be present in consolidation distal to a malignancy if the bronchus
remains patent.
-Fluid filled acinus that forms (4-10) 7mm shadow, rapidly coalesce into fluffy, ill
defined cotton wool shadows and homogenous mostly non segmental.
NB: *Air bronchogram and silhouette signs are characteristic features.
*Pulmn. Shadowing: alveolar(acinar),or interstitial.
-A ground glass appearance or a generalized homogenous haze seen with alveolar
shadowing may have a bat’s wing distribution, when a homogenous shadow
spreads, from hilae with a periph.translucent rim.(peripheral lung field spared, butterfly),
commonly due to cardiac failure and clears quickly after treatment.
Chest radiology 8
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Causes :
1. Pulmonary edema :
-Cardiac pulmn edema.
-Non cardiac (Uremia, hypoalbuminaemia, fluid overload).
2. Pneumonia :
-Localized : (pneumococcus).
-Generalized (fungi, parasites).
3. Neonatal :
-H.M.D
-Aspiration pneumonia.
4. Tumors :
-Lymphoma, leukemia.
-Alveolar cell carcinoma.
-Haematogenous metastasis (e.g. choriocarcinoma)
5. Alveolar blood :
-Pulmonary infarction, hematoma.
-Good pasture’s syndrome.
6. Miscellaneous :
-Radiation pneumonitis.
-Sarcoidosis.
Causes of Consolidation = Air bronchogram = alveolar shadows
:
-Consolidation pneumonia, TB
-Pulm edema.
-Infarction.
-Hge
-Alveolar cell ca.
-Lymphom
-HMD, ARDS
Interstitial
Shadowing :
1-Malignant tumors :
-Bronchial carcinoma..
-Secondary: (cannon ball metastasis) “very large”.
-Calcified metastasis (osteo and chondrosarcoma)
-Lymphoma.
-Plasma cytoma.
2-Benign tumors :
-Hamartoma (90% peripheral)
-Adenoma.
3-Granuloma :
-TB./ Sarcoidosis
-Histoplasmosis.
4-Infections ::
-Pneumonia,
-Abscess( Klebseilla, staph)
-Hydatid.
-Mycetoma : fungal ball.
NB: Nodular form of Fungus: Histoplasmosis. Coccidomycosis, Actinomycosis, Mycetoma
Chest radiology 11
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(Aspergillosis)
5-Vascular :
-Pulmonary infarction.
-Hematoma. -AVM.
6-Collagen disease
-Rh. Arthritis.
7-Sarcoidosis.
8-Congenital :
-Sequestrated segment.
-Bronchogenic cyst.
9-Non Pulmonary :
-Skin lesion (lateral film helps to distinguish extra pulm masses:* Intrapulmonary mass has
acute angles with lung edge. *Extrapulmonary & mediastinal masses form obtuse angles.
-Bone lesion
-Pleura (encysted effusion, plaque)
-Artifacts.
Intracavitary bodies :
-Aspergillesis : mycetoma.
-Hydatid : disintegrated.
-Lung gangrene bl. clot in cavity.
-cavitary sq. cell carcinoma.
-simple lung abscess.
Cavitation :
Causes of cavitation : (P77, same reasons as solitary nodule, but cavitation occurred, +
bronchietasis, bullae
A. Infection: Staph.(commonest), Klebsiella (abscess),TB, Amoebic, Hydatid, Fungal
(aspergillosis).
B. Malignant : Primary, 2ry, Lymphoma.
C. Aspiration abscess
D. Pulm, infarction, hematoma.
E. Pneumoconiosis : Caplan’s syndrome.
F. Cystic Bronchiectasis, sequst. lung, bronchogenic carc.
G. Sarcoidosis.
H. Bullae, pneumatocele - thin wall.
NB: Cong., trauma, inflam/inf/grannuloma, Neop., Vasc, others.
1. Intrapulmonary cavitation
2. Hydropneumothorax
3. Esophageal (pharyngeal pouch, Achalasia)
4. Mediastinal (infection, esophageal perforation).
5. Pneumopericardium (trauma, aspiration).
6. Chest wall infection, fractures.
Chest radiology 13
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NB:
* Ruptured hydatid cysts have daughter cysts floating within!cavity = water lily sign.
* Other intracavitary lesions include inspissated pus, blood clot & cavernoliths.
* Blood clots occur with cavitating neoplasm, tuberculosis & primary infarcts.
* Common in primary tumors, & irregular masses.
* Uncommon in cavitating metastases & TB cavities.
* Meniscus sign is when intracavitary body is surrounded by crescent of air,
commonly described with fungus balls such as aspergilloma, ! ball moves as : pt,
change position.
A. Intrapulmonary :
1. Granuloma, infections :
a.TB (commonest, m.imp), foci are in upper zone, scattered & of variable size.
b.Histoplasmosis characterized by focal areas surrounded by small haloes.
c.Hydatid cyst rarely (fine rim of calcification in wall).
d.Actinomycosis.
e.Chronic abscess
f. Chicken pox.
2. Tumors:
a.Metastasis (osteo, chondrosarcoma). c.A.V.M.
b.hamartoma (pop corn calcification). d.Carcinoid T.
3. Chronic pulmonary venous hypertension mitral valve disease.
4. Hematoma, infarction.
5. Alveolar microlithiasis: tiny sand like densities in mid and lower zone due to
calcium phosphate deposits in the alveoli.
6 Metastatic due to hypercalcaemia: Chronic renal failure, 2ry hyperparathy.,
M.Myeloma.
7. Rare causes as: Sarcoidosis, Silicosis (egg shell calcification).
B. Pleural : TB, asbestosis, empyema, talc, old haemothorax.
C. LN : TB, histo, sarcoid, silicosis, lymphoma after irradiation.
D. Mediastinal : cardiac, vascular, tumors.
Chest radiology 14
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A. Rotation : (positional)
1. poor technique
2. scoliosis.
B. Chest wall :
1. Mastectomy.
2. Poliomyelitis (unilateral pectoral muscle affection).
3. Poland’s syndrome (Unilateral absence of pectoral muscles + rib defect with
syndactly) in 10% of patients.
C. Pleura :
Pheumothorax.
DD: Localized transradiancy : *Bullae. *Emphysema. *Cyst. *Encysted pneumothorax.
*Pneumatocele.
D. Lung :
1. Compensatory emphysema.
2. Obstructive emphysema.
3. Macloed’s syndrome (the late sequalae of childhood bronchiolitis).
4. Unilateral bullae.
5. Congenital lobar emphysema.
E. Pulmonary vessels :
Pulmonary embolism of a major pulmonary artery at least lobar in size.
B. Bilateral :
1. Expiratory film.
2. Nodal (lymphoma, sarcoidosis, TB, carcinoma, histoplasmosis and fungi).
3. Pulmonary artery: pulmonary hypertension, congenital heart disease.
4. Extrinsic allergic alveolitis, pneumoceniosis.
B. Cardiac causes.
C. Cerebral causes (Hge, edema, drugs).
D. Metabolic causes (Acidosis, Hypoglycemia).
E. Abdominal causes (Massive organomegaly e.g. polycystic kidney).
Airway obstruction :
1. Partial hyperinflation.
2. Complete collapse.
3. Bronchocele.
4. Bronchiectasis.
5. Pneumonitis abscess.
Value of tomography :
1. To improve visualization of a lesion.
2. To localize & confirm an intrapulmonary lesion.
3. To evaluate hilum & proximal airways.
Chest radiology 18
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Chest Wall
Comment on :
A. Sternum :
1. Developmental abnormality (depressed "pectus excavatum" sternum in cong.H.D.:
ant. ribs are vertical & post ribs are horizontal, heart is displaced to the left &
appears enlarged with straight left border, prominent lung markings (Rt paracardiac)
misdiagnosed as consolidation).
2. Erosion (adjacent mediastianal mass anteriorly, infection).
3. Tumours (chondroma, chontrosarcoma, secondaries).
4. Fractures.
B. Clavical :
1. Absence outer end : (Cleidocranial dysostosis).
2. Erosion : Outer or medial end :
- Rheumatoid arthritis.
- Hyperparathyroidism.
- Infection.
3. Tumour (aneurysmal bone cyst, Ewing).
4. Fracture.
C. Ribs:
Superior or inferior unilateral or bilateral.
- Poliomyelitis
- Old age.
Fracture :
- Cough fracture (6-9) ribs at axillary line.
- Stress fracture 1st rib.
- Pathological fracture: senile osteoporosis, myleoma, cushing disease.
Selerosis :
A. Generalized (osteo-petrosis, metastasis, myelofibrosis).
B. Localized (Paget disease).
N.B: Looser’s zone : areas of uncalcified osteoid tissue (osteomalacia): rib deformity creates
Chest radiology 20
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Expansion :
a. Localised
- Paget.
- Fibrous dysplasia.
- Haemangioma.
- Aneurysmal cyst, chondroma.
- Eosinophillic granuloma.
b. Generalized :
- Thalassaemia (expansion more marked proximally + abnormal trabeculae)
- Hurlur’s syndrome (generalized expansion sparing the proximal end).
- Rickets (widening of rib ends).
D. Thoracic spine :
Comment on:
1- Alignment, disc spaces (calcification = post-traumatic, ankyloses, ochronosis,
destruction in infective process). 2-Sclerosis (single dense vertebra (ivory)=
lymphoma, paget's and metastasis. 3-Destruction (pedicle = metastases).
4- Paraspinal lines.
Diaphragm
Appearance ; (normal variants)
1. Scalloping (short curves of diaphragm, convex upward).
2. Muscle slips (small curved lines, concave upward).
3. Diaphragmatic hump or dromedary diaphragm (severe form may appear as double
contour in PA view N.B.: These is no diaphragmatic defect).
Eventration :
- Mainly left sided (thin, weak diaphragm).
- Left hemidiaphragm is elevated with mediastinal shift to the right, a feature rarely
seen with paralysis.
- May be associated with partial gastric volvulus.
- Reduced movement (seen under fluoroscopy) paradoxical movement or abscent.
Diaphragmatic movement :
On screen, normally the left hemidiaphragm move more than right by 3-6cm
Paradoxical movement : (Moves up with inspiration)
- Diaphragmatic paralysis.
- Subdiaphragmatic infection.
- Eventration.
Thickness of diaphragm :
- On left side between fundus gas and left lung (normal average of 8mm) normal
diaphragm 2-3 mm.
- If more than 8mm pathological (may be due to)
- Tumour of diaphragm : Lipomas - neurofibrimas, fibromas & cysts.
- Gastric tumour.
- Pleural effusion.
- Subphremic lesion.
Hernia of diaphragm :
Chest radiology 22
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Rupture of diaphragm :
- Trauma, surgical, may be idiopathic.
- Mainly on the left side herniation of stomach, colon strangulation.
DD : 1. Eventration (intact diaphragm)
2. Pneumothorax.
Subphrenic abscess :
- More on Rt side easy diagnosed.
- US & CT.
- Plain film :
1. Ipsilateral basal atelectasis & pleural effusion.
2. Elevated diaphragm with paradoxical or movement.
3. Gas beneath diaphragm dt. infection by gas forming org (Horizontal beam film).
4. Depression of liver edge or gastric fundus.
Rib diseases :
- Notching →Sup → NF, collagen, HPT.
→Inf. → coarctation, SVC obstruction, operation, NF.
- Sclerosis → Myelosclerosis, osteopetrosis, Paget, metastasis.
- Expansion → Dysplasia fibrous
DD : hump in PA film
Tumours ABC, haemangisms.
appears as a shadow in Rt
Blood. dis thalassemia cardiophrenic angle:
Nutritional Rickets. 1. Fat pad.
- Destruction → MM, metastasis, lymphona. 2. Lipoma.
- Fracture. 3. Pericordial cyst.
- Cervical rib & bifid. 4. Morgagni hernia.
5. Sentinel lines (bronch. pulm aspergillosis, malignancy, benign tumors ,congenital membrane.
6. Old pleural & pulm. scars (infarction, healed TB, sarcoid).
7. Curvilinear shadows : bullae, pneumatoceles.
8. Normal fissures & vessels.
9. Bronchial wall thickening.
Chest 24
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A. Organic :
1. Damage to the tracheobronchial tree:-
Occupational asthma :
-History of exposure to animal and fungal spores and in chemical industry
e.g. Byssinosis, cotton dust inhalation.
-Has the same radiological picture of asthma during attack.
2. Damage to lung parenchyma :
Extrinsic allergic alveolitis or hypersensitivity pneumonitis:
A large variety of organic dust particles & microorganisms are small
enough (1-2m, < 10m) to reach the alveoli (act as allergens) to provoke
Ag-Ab reaction within 4-6 hours after exposure. Most of allergens are
fungal spores and proteins. eg: Farmers lung, Air condition: fungal spores and drugs
Clinically :
-6 hours after exposure fever, chills, dyspnea, cough.
-No wheezes or eosinophillia.
Radiologically :
A. During acute attack :
-May be normal.
-Mainly shows ground glass appearance with loss of definition of pulmon.vessels.
-In severe cases, extensive air space filling acinar shadowing with coalescence,
picture resemble pulmonary edema.
B. Between attacks (normal) :
-In subacute phase: reticulonodular pattern (fine lines together with small nodules
(1-3 mm).
C. With repeated attacks : pulmonary fibrosis :
Characterized by coarse lines particularly in mid and upper zones, together with
ring shadows 5-8mm causing honey comb appearance which is predominant in
upper zones (DD fibrosing alveolitis).
Chest 25
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B. Inorganic :
Damage to lung parenchyma and pleura:
2. Silicosis :
Due to exposure to silica particles e.g. sand blasting and pottery, ceramic industries.
Radiologically :
Very similar to cool workers pneumoconiosis which mainly differentiated by egg-
shell calcification of enlarged hilar lymph nodes.
Simple forms : As cool workers pn. with or without hilar lymphadenopathy.
Complicated: As cool workers pn.
NB: Two important diseases may occur in association with silicosis and coal workers
pn. (TB and Bronchial carcinoma).
Chest 26
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3. Asbestosis :
The asbestos fibers, when inhaled, pass to the respiratory bronchioles and acini,
where they are engulfed by Macrophages and evoke a fibrotic response. Also, they
may penetrate visceral pleura, causing pleural reaction.
A. Pulmonary changes :
-Predominantly in lower lung zones (DD silicosis upper)
-Earliest changes are seen in costophrenic angles.
-At first the vessels have indistinct margins & are associat. with fine irregular lines.
-When fibrosis progress lines become more profuse reticular network pattern.
-With more progression give honey comb pattern, which is best seen in lateral
and oblique views
-Complications : Bronchial carcinoma, which is strongly related to cigarette
smoking.
NB: Fine irregular line Reticular network honey comb.
B. Pleural changes:
1. Pleural plaques :
-They are not seen for at least 10 years following exposure.
-They usually do not calcify until a latent period of 20 years.
-They are of variable size and have a characteristic distribution on parietal pleura.
a. Adjacent to ribs more prevalent in the axillary part of midchest and tend
to spare to upper zones and costophrenic angles.
b. Over central tendon of diaphragm which produce characteristic curvilinear
opacities on diaphragmatic pleura. Best seen in oblique views.
-CT is very sensitive for early detection.
2. Malignant Mesothelioma :
-The majority of such tumor is related to asbestos exposure and it does not arise
from pleural plaques.
-Appear as (see pleural diseases) nodular pleural thickening / hemorrhagic effusion/ central
mid diaphragm dt collapse / Rib involvement may occur.
Causes :
1. Inorganic dusts: (Silica, Asbestos inhalation).
2. Organic dusts: (Extrinsic Allergic Alveolitis).
3. Drugs, poisons and toxic fumes.
4. Fibrosing alveolitis (Interstitial Pneumonia): Cryptogenic & Secondary lower
zone.
5. Histocystosis X.
6. Sarcoidosis.
7. Neurofibromatosis.
8. Tuberous sclerosis.
9. Adult respiratory distress syndrome.
10. Lymphangiomyomatosis.
11. Chronic pulmonary edema.
12. Collagen dis. (Rhtoid basal/ SLE/ AS upper/scleroderma/ PAN /Wegner
granuloma/Loffler’s. ).
NB: *Key (clinically, defin, ground glassreticulonodular honey combing
*5C : Cough/ cyanosis/ clubbing/ crepitation/ Cor pulmonale.
Clinically :
-Middle age patients presented with presented with dyspnoea, dry cough, clubbing
of fingers, basal crepitations.
-Lung functions studies restrictive defect.
Radiological features :
1. In earliest stage :
-Lungs may look normal.
-The earliest minimal changes appear :
1. Ground glass (Haze) in bases …. more easily seen in both cardiophrenic
angles (mainly unequal with more on right) which extend upward and
outward to costophrenic angles forming:
2. Generalized ground glass haziness of lungs.
2. With progression :
The pulmonary vessels lose their normal clarity and a fine reticulo nodular
pattern develops in the lower zones.
3. With more progression :
-Give (honeycomb appearance) coarse reticular pattern (at base) and ring
shadows (5-10mm).
-Best seen in post-costophrenic angle in lateral view.
-CT is very sensitive in early detection.
Chest 30
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2. Histocystosis X :
A disease of unknown etiology, usually affects multiple organs including the lungs.
Abn. proliferation of RE cells in (Bm - lung - HSM - LN).
3 varieties :
1. Eosinophillic Granuloma (mainly affect lungs).
2. Hand-Schullar Christian disease.
3. Laterer-Siwe disease.
Eosinophillic Granuloma :
Young adults (male : female = 4.1)
Pathology :
There is histocytic infiltration of the alveolar walls leading to its fibrosis
causing disorganization of the pulmonary architecture with formation of air cysts.
Radiological features :
-Wide spread, bilateral and symmetrical.
-In earliest stage normal.
-Reticulonodular pattern diffuse nodular shadowing in mid and upper zones (1-
10mm) associated with fine lines.
-With progression give honey comb appearance.
-Spontaneous pneumothorax in 20% (dt air cysts).
-Pleural reaction and hilar lymphadenopathy (rare).
-Open lung biopsy is best method to confirm diagnosis.
III. Sarcoidosis :
Multisystemic, granulomatous disorder of unknown etiology, characterized by
presence of non caseating epithelioid cell granolumas with predilection to involve
lungs, skin, L.N., adrenal, uveal tracts, C.N.S and bone.
Incidence :
(30-50ys), more common in black races, female: male =2:1).
Diagnosis :
1. Clinical data.
2. Radiological findings.
3. Histopathology. Broncho alveolar lavage.
4. Kveim test: intradermal injection of extract of sarcoid tissue reaction = +ve.
5. Gallium 67 scanning (taken by nodes and parenchymal lesions).
Chest 31
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Radiological findings :
The radiographic abnormalities progress through 3 stages :
1. Lymphadenopathy only.
2. Lymphadenopathy + pulmonary lesions.
3. Pulmonary lesions only.
1. Small nodules :
2-3mm rounded or irregular nodules, slightly well defined (miliary) and
symmetrical, bilateral mainly uniform in distribution from apex to base.
2. Reticulation :
-A network of fine lines radiating from hilae.
-Kerley’s B lines may be seen from lymphatic seedlings.
3. Reticulonodular: more common, + pleural effusion & thickening.
4. Large nodules:
Multiple bilateral 1-4cm in diameter, rounded or oval in shape, usually with ill
defined border.
5. Homogenous cloudy opacities :
-Commonly contains air bronchogram giving features of consolidation.
-May be single or multiple, range from 1 cm to a segment.
-2/3 of parenchymal shadowing clear completely and 1/3 progress to :
6. Fibrosis :
-Coarse linear shadows with evidence of volume loss+ ring shadows+honey comb.
-Condensation and contraction of the fibrous tissue produces:-
1.Distortion of pulmonary architecture.
2.Elevation of hilae i.e displacement of landmarks.
X-ray staging :
0 normal
1 bilat hilar LN
2 adenopathy + pulm infiltrate
3. pulm infiltrate alone.
V. Neurofibromatosis :
The same as in Histocystosis X.
1. S.L.E.
Characterized by widespread inflammatory changes in CT, B1vs and serosal surface.
Radiological features :
1. Pleural effusion - Mostly bilateral, small, associated with pleuritic pain.
2. Segmental basal collapse : Thick horizontal band shadows at lung bases,
which occurs due to restricted diaphragmatic movement by pleurisy.
3. Pulmonary consolidation either due to (2ry infection or lupus pneumonitis).
4. Pulmonary edema : secondary to heart failure.
5. Diffuse interstitial shadowing : as in fibrosing alveolitis (rare).
6. Diminished diaphragmatic excursion: may be due to myopathy of the
diaphragmatic muscles.
Chest 34
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IV. AnkvlS:
-Unilateral or bilateral.
-Upper lobar fibrosis with upward retraction of hilae + bullae formation.
-Apical pleural thickening.
V. Polyarteritis Nodosa :
-Vasculitis of medium sized arteries.
-Kidneys most commonly affected.
Radiologically :
-Transient areas of consolidation which may appear rapidly then disappear
(Loeffler’s syndrome).
- Accentuation of vascular lung markings.
- Large nodules (few cm) may cavitate.
Radiological appearance :
A. Free effusion (in the absence of pleural adhesions).
1. Small effusion:
-< 100 cc; can not be detected by PA and lateral films but detected by decubitus
view, U/S and CT.
-100-200 cc: Can fill the posterior costophrenic recess and appear in lateral film,
Chest 38
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Radiological appearance :
A. Costal encysted pleural effusion :
-Site : Along the chest wall (usually posterior and laterally).
Chest 39
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-R.A: Their radiological appearance depends on whether they are viewed en face,
in profile or obliquely.
-Best determined by fluoroscopy:
*Profile: well circumscribed, biconvex opacity with the peripheral border
adjacent to the chest wall and the inner border is convex and well defined.
*En-face: Radio-opacity of relatively low density.
*If air fluid level is seen it will be either due to therapeutic aspiration, or
development of bronchopleural fistula.
* Interlobar effusion disappears rapidly after ttt, and may recur in subsequent episodes
of heart failure so known as pseudo or vanishing tumors, phantom tumor
* Subpulmn encysted effusion : same as free effusion but the fluid doesn’t move into
pleural space with changing posture.
* Encysted mediastinal pleural effusion : mimic a mediastinal mass, diagnosis by
CT.
Effusion :
Free/ atypically ( lamellar, / subpulmonary).
Encysted (costal encysted, interlobar, mediastinal, subpulmonary
Chest 41
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II. PNEUMOTHORAX
Definition : Air within the pleural cavity due to defect in parietal or visceral pleura.
Etiology :
1. Spontaneous pneumothorax :
-Is the commonest type.
-In young adults cong. pleural bleb (usually in lung apex).
-Children staph. pneumonia.
-Old age Emphysema or chronic bronchitis.
-Other causes :
*Rupture of subpleural TB focus.
*Rupture of subpleural cyst in bronchial carcinoma or rupture of cavitating
metastasis.
*Conditions associated with interstitial pulmonary fibrosis, cystic fibrosis
Sarcoidosis.
2. Traumatic pneumothorax :
-Chest trauma due to : penetrating wound, closed chest trauma, fracture rib.
-Pleural or lung biopsy.
-Bronchoscopy and oesophagoscopy.
-C.V.P catheters introduction.
Radiological appearance :
A. A small pneumothorax :
-In the erect position, small pneumothorax collects at the apex and appears as a
small radiolucency in the pleural space which is devoid of lung markings. The
apex of lung retracts towards the hilum. The sharp white line of visceral pleura
will be visible.
-Expiratory films diagnostic, since on full expiration, the lung volume is at its
smallest while volume of pleural air is unchanged.
B. Large pneumothorax :
-A large radiolucency, which is devoid of lung markings.
-Lung retraction.
-Mediastinal shift toward the normal side which increase with expiration.
Chest 42
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Complications of pneumothorax :
1. Encystment pneumothorax: due to pleural adhesion.
R.A.: Ovoid, radiolucency adjacent to the chest wall.
D.D.: Subpleural cyst and bulla.
2. Pleural adhesion:
R.A:. Appears as a line shadow between the two pleural layers preventing
relaxation of the underlying lung.
Rupture of this adhesion may produce hydropneumothorax.
3. Lobar collapse or consolidation:
4. Pleural fluid collection :
-Small amount fluid level at costophrenic angle.
-Large amount hydropneumothorax “ horizontal air fluid level”.
5. Pleural thickening :
-In chronic cases, thickening of visceral or parietal pleura may occur.
-Thickening of the visceral pleura may prevent re-expansion of the lung
which needs decortication.
* Cardiac Tamponade
NB:
1. open air in pleura communicate with atmosphere.
2. closedeg: ruptured bleb(So not open). increase pleural pr. but still -ve
3. Tension valve like tear air in not out !! increased pleural pr.
Chest 43
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Causes :
1. Pleurisy : primary, secondary to lung infection or infarction.
2. Previous low grade TB infection apical.
3. End result of empyema, haemothorax.
4. Following radiotherapy of the chest.
5. After asbestosis exposure diffuse pleural plaques.
6. Old age.
7. Malignancy
Common sites :
1. End of pleural fissures.
2. Apices of the lung.
3. Whole pleura (diffuse pleural thickening).
Radiological appearance :
Radiological appearance :
-Continuous sheet or discrete plaques - usually producing dense, coarse, irregular
shadows.
-When viewed tangentially - characteristically parallel to the chest wall.
-When viewed en face bizarre form of calcification, which may cast an ill
defined shadow mimic to pulmonary infiltrate.
V. BRONCHOPlEURAL FISTULA
Causes :
1. Complication of pneumonectomy.
2. Rupture of lung abscess or empyema.
3. Carcinoma of nearby bronchus.
4. Penetrating chest trauma.
Radiological appearance :
Plain :
Picture similar to hydro or pyopneumothorax (if persists or enlarges after surgery,
BP fistula should be considered).
Contrast study :
-Injection of lipidol or hydrast into pleural space (sinography or passes into the
bronchial tree.
-Injection into bronchial tree passes to pleural space.
Chest 45
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Pleural fibroma :
Usually associated with hypertrophic osteoarthropathy joint pain and clubbing.
Radiological appearance :
Well defined lobulated mass :
- Site : Costal, diaphragmatic, mediastinal or at pleural fissures.
- Size : Small or occupy most of hemithorax.
Subpleural lipoma :
- Well defined rounded masses.
- May change their shape with respiration (fluoroscopy).
Malignant mesothelioma :
Usually due to prolonged exposure to asbestdust.
Radiological Appearance :
- Nodular pleural thickening around all or part of a lung.
- Hemorrhagic pleural effusion may be present, which may obscure ! mass.
- Mediastinum is mainly central despite of the presence of a large effusion due to
underlying collapse of the lung by:
*Ventilation restriction by the tumor.
*Bronchial ??/ stasis by tumor compression.
- Rib involvement may occur not common as in metastasis.
- Other asbestosis changes (pleural thickening, pl. calcification)
- CT is the best method for assessing the extent of malignant mesothelioma.
- Percutaneous or U/S needle biopsy is diagnostic.
Chest 46
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CHRONIC OBSTRUCTIVE
AIRWAY DISEASE
I-Bronchial asthma :
Radiological appearance :
II-Chronic bronchitis :
Emphysema :
Definition : Enlargement of airways beyond (distal) to the terminal bronchioles with
dilation and destruction of their walls.
NB:- *Trachea, bronchi & bronchioles are strictly conducting airways.
*Resp. bronchioles, alveolar ducts & alveolar sacs-conducting & respiratory structures.
*Alveoli are purely respiratory function.
*Bulla : emphysematous space with diameter > 1 cm in the distended state & its walls are
made up of compressed surrounding lung or pleura.
Chest 48
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Types of emphysema :
1.Panacinar : Panlobular :
- Non selective process, characterized by destruction of all the lung distal to the
terminal bronchiole. ??Alpha-1-anti-trypsin deficiency.
- It may be localized or generalized.
2. Obstructive emphysema : misnomer : obstructive hyperinflation (bec. distal airway
is not necessarily destroyed).
- It occurs, when a larger bronchus is partially occluded by an intra-luminal mass
ball valve effect of this mass, in such a way that air enters the lung on
inspiration but is trapped on expiration.(FB or peribronchial tumor).
3. Para-cicatricial emphysema:
-Distention & destruction of terminal air spaces adjacent to fibrotic lesions eg TB.
4. Congenital lobar emphysema :
- Refers to an overinflated lobe which compresses adjacent normal lung producing
respiratory distress mainly in the neonatal period.
- Causes :
1. Deficiency of a bronchial wall cartilage.
2. Obstruction to a lobar bronchus by an extrinsic mass or anomalous vessels.
3. Alveolar abnormality
*Polyalveolar lobe increased number of alveoli in a lobe
*Rigid alveoli with surrounding stroma.
5. Unilateral or lobar emphysema (Macleod’s syndrome):
- It is probably the result of a childhood viral infection causing bronchiolitis and
obliteration of the small airways, the involved distal air ways are ventilated by
collateral air drift air trapping of pan-acinar type.( hypertransradiant hemithorax
dt decrease perfusion.)
Causes of unilateral lung transradiancy :
Chest 49
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1. Centri-acinar : centrilobular.
- Selective process, characterized by destruction and dilatation of respiratory
bronchioles, where the alveolar ducts, sacs and alveoli are spared.
- It is frequently found in chronic bronchitis.
2. Focal dust emphysema :
- Similar to centri-acinar emphysema, but in association with cool dust exposure.
3. Para-septal emphysema:
- Usually involves the periphery of the secondary lobules at the lung periphery
occasionally causes bullae formation.
4. Senile emphysema :
- Dilatation of the alveolar ducts due to the aging process.
- Non significant.
5. Compensatory emphysema (hyperinflation):
- Hyperinflation of the unaffected or remaining lung due to collapse of a part or all
of the lung.
Radiological appearance :
The classical radiographic appearance of advanced emphysema consists of a triad
of findings (overinflation, vascular damage, bullae).
I. Panacinar :
2. Vascular changes :
A. In widespread, generalized emphysema:
- The midfield and peripheral pulmonary vessels are attenuated in both size and
number, where the normal smooth gradation in size of vessels from the hilum
outwards is lost.
- The hilar vessels being larger than normal with abrupt tapering.
B. Localized emphysema :
Chest 51
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Radiological appearance:
a. Rounded or oval translucency, more than > 1cm in size.
b. Smooth, curved, hair line wall (compressed lung parenchyma.)
c. Causing distortion or displacement of pulmonary vessels.
d. May be single or multiple.
e. Usually peripheral.
Giant bullae :
Chest 52
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1. Plain :
-Hyperlucency of the affected lung due to attenuation of vessels within it.
-Air trapping effect of the affected lung, but no over inflation as above.
2. Bronchography :
Not usually indicated, but shows a characteristic app.:
- Main and segmental bronchi are normal.
- Irregular dilatation of peripheral bronchi till, 6th order division.
- Lack of bronchial filling distal to the 6th order division (bronchiolitis obliterans)
giving pruned tree appearance.
3. Pulmonary angio:
- Not commonly used, reveals: attenuation of pulmonary vasculature of the
affected side.
4. Isotope :
- perfusion scan shows decrease flow.
- Ventilation scan air trapping
- Variable degree of overinflation of one lobe mostly the upper & middle lobes →
show hyperlucency with few visible lung markings.
- The over expanded lobe leads to
1. Compresses remaining lung
2. Flattens or inverts ipsilateral lung
3. Mediastinal shift towards opposite side.
4. May herniate across the midline to opposite side.
Pink Buffer :( Pt. by major effort ventilates sufficient to maintain normal bl. Gases).
More common with pan acinar emphysema.
- Manifestation of hyperinflation.
- Peripheral vascular attenuation.
“Where we call arterial deficiency pattern of emphysema”
DD of Emphysema:
COLLAPSE (ATELECTASIS)
Collapse means partial or complete loss of volume of a lung.
2. Cicatrization collapse :
The lung can not normally expand (decrease lung compliance) decrease it
volume. Occur in pulmonary fibrosis.
3. Adhesive collapse :
Normally the surface tension of the alveoli is decreased by surfactant
disturbance of such mechanism leads to alveolar collapse with patent major
airway. e.g. respiratory distress syndrome in premature.
PATTERNS OF COLLAPSE
A. Entire lung collapse “complete collapse”:
Acute obstruction to one of the main bronchi lung collapse and causes
1. Opacification of the hemithorax.
2. Displacement of the mediastinum to the affected side.
3. Elevation of the diaphragm.
4. Rib approximation.
5. Compensatory hyperinflation of contralateral lung.
a. Hyperlucency with accentuation of its vascular marking.
b. Widening of rib spaces.
c. Herniation across mediastinum, mainly occur in the retrosternal space or in
azygo-ocsophageal recess posteriorly or across the midline.
B. Lobar collapse:
PA view : -The outer aspect of minor fissure moves upward with concavity inferior.
- Tracheal shift to the right.
- Loss of definition of shape of right border of superior mediastinum
(Silhouette sign),
Chest 59
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3. Lingular collapse :
Mainly involved in left upper lobe collapse :
PA view : Loss of definition of the left cardiac border.
Lat. view : Ant. displacement of lower part of oblique fissure and increased opacity anterior to it.
Chest 60
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C. Multilobar collapse :
Right middle and lower lobe collapse dt to obstruction of bronchus intermedius.
PA view :
- A triangular shadow, with its apex at hilum and its base on diaphragm extending
laterally to costophrenic angle.This distinguish it from isolated lower lobe
collapse.
- Obliteration of diaphragm and right cardiac border.. DD: subpulmonary effusion
or elevated right diaphragm.
Lat view :
Radio opacity of a well defined upper border extending downward and forward
from back to front which obliterates the whole hemidiaphragm.
CONSOLIDATION
Definition: Means replacement of air in one or more acini by fluid or solid
material. The smallest unit of consolidation is a single acinus which
casts a shadow approximately 7mm in diameter.
Causes of consolidation:
- The most common cause is acute inflammatory exudation associate with
pneumonia.(TB, infarction, collapse), (same as causes of alveolar and acinar shadows)
- Other causes:
- Pulmonary edema.
- Hemorrhage, aspiration.
- Alveolar carcinoma, lymphoma.
Consolidation is either : patchy, segmental, or lobar
Consolidation :
- When associated with patent air way air bronchogram is seen with to change
in volume .
- When it occurs secondary to bronchial obstruction no air bronchogram seen
and there is decrease in lung volume = consolidation collapse.
OBSTRUCTIVE PNEUMONITIS
OBSTRUCTIVE HYPERINFLATION
See emphysema
BRONCHIECTASIS
Etiology :
Commonly due to a severe, recurrent or persistent infection which leads to
dilation of large airways and obstruction with destructive process of smaller ones
bronchiolitis obliterans.
NB: Inflammation & destruction: large bronchi dilated (yield under pr.)
* Small obstructed (bronchiolitis obliterans).
*Non infective bronchial wall damage : occurs following inhalation of toxic gases and
allergic damage of aspergillosis.
Site :
- May be localized, multifocal or generalized.
- It is commonly basal but it may be confined to upper zone e.g. TB.
3. Fusiform bronchiectasis :
- Varicose bronchiectasis with preserved side branches.
- This appearance, typically at segmental or subsegmental level is highly
suggestive of allergic aspergillosis.
Radiological features :
1. It may be normal in 7%
2. Peribronchial thickening and retained secretions.
3. Cystic spaces = air fluid levels.
4. Crowded vessels i.e loss of volume.
5. Coarse honeycomb pattern in very severe disease.
PULMONARY NEOPLASM
Benign : Intrabronchial tumors (adenoma), pulmonary tumors (hamartoma, angioma)
Malignant : Bronchial, carcinoma., others, metastasis, malig, lymphoma, (carcinoid,
cylindroma).
Radiological features :
2. Border (edge):
- Lobulated, notched (umblicated) or irregular ill-defined.
- Corona radiata: Numerous fine strands may be seen radiating into lung from
mass with more transradiant lung parenchyma than normal between these
strands which is highly suggestive for carcinoma.
6. Mass effect:
- Bronchocele, due to obstruction to the segmental or subsegmental bronchus.
- Appear as peripheral tubular density which may branch &occur distal to the
mass.
C. Spread of tumor :
2. Mediastinal invasion :
- Can not be evident on plain film, unless phrenic nerve is invaded.
- CT can provide evidence of mediastinal invasion.
- Phrenic nerve paralysis high hemidiaphragm on chest X-ray.
*Cause of high hemidiaphragm in Br. carc.
- Phrenic nerve paralysis.
- Lower lobe collapse.
- Subpulmonary effusion.
- Liver enlargement (2ry to metastasis).
5.Blood metastasis : To :
- Suprarenal gland (common) or by “lymph spread”.
- Ipsilateral lung, ribs and spine.
6. Lymphangitis carcinomatosa.
7. Pulmonary osteoarthropathy.
It is a subtype of adenocarcinoma.:
C/P : Cough with production of mucoid sputum (mucus is produced by malignant
cells.
A. Local form:
-Often presents as a peripheral pulmonary nodule which is usually
indistinguishable from other cell types .
- Air bronchogram may be seen within a nodule, because the cells line the alveoli,
but do not compress air ways.
DD:
1. Pulmonary edema.
2. Widespread broncho pneumonia.
Chest 72
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*Summary
- Central mass + collapse + pneumonia DD LN
- Peripheral size, shape, edge, cavitation, calcification, bronchocele, tail
- Spread: Hilum, medist, chest wall, pleura, blood, lymphangitis + Pulmn osteoarthropathy.
- Alveolar cell (local, diffuse).
- Metastotic lung
- Lymphoma
METASTATIC TUMOURS
A. Pulmonary metastasis :
- Are due to haematogenous spread from breast, GIT, kidney, tests and from a
variety of bone and soft tissue sarcomas.
- Appear as, one or more discrete pulmonary nodules, which are usually spherical
and well defined but it may take any shape and may be irregular.
- A solitary metastasis may be a presenting feature without a known primary tumor.
- Solitary large cannon ball metastasis usually with renal cell carcinoma (hyper
nephroma).
- Cavitation may be seen particularly in metastasis, composed of squamous cell
carcinoma risk of pneumothorax.
- Calcification (rare) except in osteosarcoma and chondrosarcoma.
- Rate of growth is variable: Very rapid: osteosarcoma, slow: thyroid malignancy. .
C. Lymphangitis carcinomatosis :
- It is a from of metastatic carcinoma in which the pulmonary lymphatics are
invaded and blocked by cords of malignant cells.
- It may be unilateral or bilateral.
- The commonest causes are bronchial carcinoma, breast, stomach, colon, pancreas
and prostate.
- Bronchial carcinoma is ! commonest cause of unilateral lymphangitis
carcinomatosis.
Mechanism :
1. Lymphatic permeation, radiating from tumor in hilar lymph nodes.
2. Or it is probable that initial dissemination is via blood stream and invasion of
intrapulmonary lymphatics takes place with permeation of tumor towards hilae
and with no initial involvement of hilar lymph nodes.
Radiologically :
- Wide spread, ill defined 2-3 mm nodular pattern together with wide spread
thickening of the pulmonary septa.
- The fissures may be thickened by subpulmonary edema.
- Pleural effusion common but small. - Signs of associated lesion as bronchial carc.
Chest radiology 74
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Lymphangitis carcinomatosis:
- Miliary Metastases.
- Lymphatic permeation.
- Interstitial fibrosis.
DD : Pulmonary edema.
Endobronchial metastasis :
- Unusual.
- Renal and colonic carc. are ! commonest primary tumor to give rise to
endobronchial metastasis.
- Radiologically : Effect of air way obstruction is the dominant feature.
Military metastasis :
- Miliary pattern with no evidence of lung masses or associated lymphatic obstr.
- The commonest causes are : (Thyroid, renal, trophoblastic carcinomas).
Pulmonary hypertension :
- Tumor emboli may block small pulmonary arterioles.
- Picture of pulmonary hypertension.
- It is a particular feature of choriocarcinoma.
Chest radiology 75
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MALIGNANT LYMPHOMA
Radiological features:
1. Carcinoid tumors :
- Arise from APUD system (argentaffin cells).
- Central (bronchial obstruction – Extrabronchial mass).
BENIGN TUMOURS
A. Intrabronchial tumors :
B. Pulmonary tumors :
2. Angioma :
a. Capillary haemangiomas.
b. Cavernous haemangiomas.
c. AV malformation.
- Often reveals multiple lesions.
- Spontaneous rupture (pulmonary haematoma).
- Draining vein + feeding artery.
3. Neurofibroma.
1. Neoplastic :
1. Malignant : (1ry, metastasis, lymphoma)
2. Benign : (Hamartomas, neurofibroma)
2. Inflammatory:
1. Granuloma: TB, Histoplasmosis.
2. Chronic abscess.
3. Parasitic (Hydatid cyst), fungball.
3. Vascular :
1. Pulmonary haematoma.
2. Pulmonary infarction.
3. AVM.
4. Others :
1. Bronchogenic cyst.
2. Mycetoma (fungal ball).
3. Sequestrated lobe.
4. Rheumatoid
5. Outside :
Psendopulmonary mass (cutaneous mass, bony lesion, pleural “encysted effusion,
tumor plaque).
Chest radiology 79
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A. Infective (Abscess)
- Staph. aureus and klebsiella.
- TB.
- Aspergillosis, Hydatid, amoebic.
B. Neoplastic :
- Bronchogenic carcinoma. (squamous)
- Metastasis.
- Lymphoma.
C. Vascular :
Infarction due to :
- 1ry infection (septic emboli) = pyemia.
- 2ry infection (of a non septic infarction).
D. Abnormal lung : (cong)
1. Cystic bronchiectasis.
2. Infective emphysematous bullae.
3. Sequestrated lung.
4. Bronchogenic cyst.
E. Granuloma ;
1. Sarcoidosis.
2. Rheumatic nodule.
3. Progressive massive fibrosis.(Pneumoconiosis)
F. Traumatic :
1. Haematoma.
MEDIASTINUM
Region I:
1. Retrosternal goiter.
2. Thymic tumors.
3. Aneurysm of ascending aorta.
4. Tortuous innominate artery.
5. Lymphangioma.
Region II:
1. Teratodermoid tumors (germinal cell neoplasms)./young adult-doesn’t displace trach.
2. Thymic tumors.
3. Sternal tumors (2ries, primary “chondrosarcoma, myeloma, lymphoma, giant
cell tumors”)
Region III :
1. Fat deposition and pericardiac pad of fat.
2. Morgagni hernia.
3. Pleuropericardial cysts.
4. Diaphragmatic hump.
5. Lipoma.
Chest radiology 81
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THYROID TUMORS
Less than < 5% of enlarged thyroid glands in the neck extend into the mediastinum to
produce a retrosternal goiter.
Clinically :
- Soft tissue swelling that moves on swallowing.
- Dysphagia, stridor and superior vena cava compression syndrome in malignancy.
Radiographic features :
Plain :
- An oval soft tissue mass in the superior part of the anterior mediastinum, which
extends downward from the neck.
- The outline is well defined in the mediastinum but fades off in the neck due to its
anterior location.
- The mass commonly projects to the right side of mediastinum with displacement
and compression of the trachea to the left.
- In 20%, the goiters are retrotracheal posterior displacement of the esophagus
and the trachea.
- The mass may contain central nodular, linear or crescentic patterns of
calcification (not a sure sign).
Isotope scanning :
Shows an area of increased activity extending below ! sternal notch (diagnostic).
Biopsy.
Chest radiology 82
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THYMIC TUMOURS
Presentation :
- Anterior mediastinal mass in non symptomatic adult patient.
- Myasthenia gravis in 10% of cases.
Radiographic features :
Plain :
- A round or oval soft tissue mass, projects to one side of the anterior mediastinum.
- It may contain a peripheral rim or central nodules of calcification.
- Thymolipoma : a very large soft tissue mass with less radiographic density which
changes its shape with respiration.
- Malignant thymoma pleural metastasis.
CT :
1. Shows a soft tissue mass in the anterior mediastinum which occasionally
contains calcium or cyst fluid.
2. Demonstrates the signs of invasion in malignant thymomas.
3. CT guided biopsy can confirm the diagnosis.
Lateral tomography :
Can show the outline of such a mass.
Chest radiology 83
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TERATODERMOID TUMOURS
Origin :
- All are thought to arise from primitive germ cell rests in the urogenital ridge.
- About 70% of teratodermoid tumors are benign.
Presentation :
- Anterior mediastinal mass in an asymptomatic young adult patient.
- Dyspnea, cough and chest pain.
Radiographic features :
Plain :
A. Benign dermoid cyst :
- Appears as round or oval soft tissue mass, usually project to one side of anterior
mediastinum.
- The outline is well defined but becomes irregular in very large tumors due to
peripheral atalectasis in surrounding compressed lung.
- The mass may contain a peripheral rim or central nodules of calcification, a fat
fluid level or a rudimentary tooth which is a diagnostic sign.
B. Malignant teratoma :
- Appears as a lobulated soft tissue mass which projects on both sides of the
anterior mediastinum.
Computed tomography :
Solid mass of variable attenuation densities which contains soft tissue, cyst fluid,
calcium, bone or fat.
Chest radiology 84
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Presentation :
- Soft tissue swelling that transilluminates in the root of the neck in children.
Radiographic features :
1. Plain :
- Appears as an oval soft tissue mass in the superior part of the anterior
mediastinum which extends up into the neck.
- It can alter in shape on respiration, but does not displace the trachea.(DD: goitre)
2. CT confirms the diagnosis :
- Cystic swelling.
- Fluid density.
FAT DEPOSITION
- Excessive deposition of fat in the mediastinum usually presents with widening of the
superior part of mediastinum and large epicardial pad of fat in asymptomatic obese
patient + Cushing.
- Diagnosis is confirmed by CT :
- DD :
1. Mediastinal lymphadenopathy.
2. Dissecting aortic aneurysm.
PLEUROPERICARDIAL CYST
1. Plain :
- A round, oval or triangular soft tissue mass in the anterior or middle mediastinum
which alters its shape on respiration.
- About 75% of pleuropericardial cysts occur in right anterior cardiophrenic angle.
2. CT :
- Thin walled cyst containing fluid of low attenuation (0-10 H.U.) = Spring water
cysts.
Chest radiology 85
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MORGAGNI HERNIA
Anatomy :
- The foramen of morgagni is a persistent developmental defect in the diaphragm
anteriorly between the septum transversum and the costal origin of the
diaphragm.
Presentation :
- An anterior mediastinal mass in an asymptomatic adult patient.
- The hernia can produce retrosternal chest pain, epigastric pain and dyspnea.
- More than 90% of morg. hernias are situated in the right anterior cardiophrenic
angle due to the protective affect of the pericardium on the left.
Small hernias :
- Contains omentum, which appears as a rounded soft tissue mass.
Large hernias :
- Contain small or large bowel or stomach.
- Appear as soft tissue mass containing either gas or gas fluid levels.
- Barium studies (meal, follow through and enema) confirm the diagnosis e.g. a
loop of transverse colon above the diaphragm and within the chest.
Chest radiology 86
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Presentation :
- An ectopic parathyroid gland in the chest.
- Usually presents with hypercalcaemia in an adult patient with hyper-
parathyroidism.
Radiological features :
- Plain chest normal.
- Abdomen nephrocalinosis or renal calculi.
- Skeletal changes of hyperparathyroidism.
The diagnosis is confirmed by isotope scan.
LIPOMA
Plain : A round or oval soft tissue mass with radiographic density and can alter in
shape on respiration.
CT : Solid mass of fatty attenuation (-50 to - 100 H.U.)
Metastatic diseases :
- Intrathoracic (bronchial carc., cancer oesoph).
- Extrathoracic (breast, renal, adrenal, testicular, pharyngeal, laryngeal, thyroid).
Bronchial carcinoma :
- Is the commonest primary tumor to metastasize in mediastinal LN.
- It produces either:
* Unilateral hilar mass with an irregular lobulated outline.
* Widening of superior part of middle mediastinum due to a superior vena caval
compression syndrome.
Esophageal carcinoma :
- May involve the posterior mediastinal lymph nodes.
Renal and adrenal tumors :
- Can metastasize to the right hilar LNs.
Testicular tumors : Paratracheal L.N.
Lymphoma :
- Usually involves the paratracheal and tracheobronchial lymph nodes producing
asymmetrical bilateral widening of the superior part of the middle mediastinum.
- Involvement of subcarinal lymph nodes splaying of the carina.
- Peripheral calcification occasionally occurs in the lymph nodes egg shell
calcification.
Primary TB :
- Produces an area of consolidation in one of the lobes and a unilateral hilar
enlargement.
- Calcification may develop in both primary Ghon’s focus and mediastinal lymph
nodes as healing occurs.
Fungal infections :
- Such as Histoplasmosis and coccidioidomycosis.
- May produce enlargement of the hilar or paratracheal lymph nodes.
- Calcification may occur in healing stage.
- Actinomycosis is ! only fungus causing unilateral hilar lymphadenopathy : USA.
Causes in cardiovascular :
Presentation :
- Chest pain radiating to back (dissecting).
- Hoarseness of voice due to traction on Recurrent laryngeal Nerve.
- Dysphagia.
Radiological features :
Plain :
a. Widening of the mediastinum.
b. A round or oval soft tissue mass in any part of mediastinum with a well defined
outline.
c. Sometimes a peripheral rim of calcification.
d. May also involve adjacent bones producing :
1. Pressure erosion of the sternum.
2. Anterior scalloping of one or two vertebral bodies.
Fluoroscopy :
- Pulsatile masses are not a sure sign, because any mass adjacent to aorta transmits
its pulsation.
Thoracic aortography (& DSA, MRI )
- Confirm the diagnosis except if the aneurysm is thrombosed.
Computed tomography :
- Shows a dilated aorta containing a central lumen of blood of high attenuation
(80-100 H.U.) due to enhancement of the blood pool with water soluble contrast
medium (true).
- A peripheral layer of clot of lower attenuation which may contain calcification
(false lumen). The subintimal flap and false lumen of a dissecting aneurysm can
be demonstrated by CT.
Produces widening of the superior part of ! mediastinum on the right side without
displacement of the aorta
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Can produce an apparent left hilar mass, through which the hilar vessels can be seen.
Dilatation of superior vena cava produces widening of the superior part of the
mediastinum on the right.
BRONCHOGENIC CYST
Region I (Paravertebral):
1. Neurogenic tumors.
2. Other paravertebral masses.
3. Anterior thoracic meningocele.
Region II :
1. Dilated esophagus.
2. Aorta unfolded, dilated or aneurysmal.
3. Neuroenteric cyst.
4. Enteric cyst : is an intestinal duplication cyst related to oesoph.
Region III :
1. Hiatus hernia. 2. Bochdalek hernia.
3. O: Pseudopancreatic cyst, extra medullary haemopoietic system
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NEUROGENIC TUMORS
Radiological features :
1. Plain x-ray :
Neurofibroma :
- Neurogenic tumor appears as a round or oval soft tissue mass with well defined
outline in the paravertebral gutter which project to one side of posterior
mediastinum.
- Enlargement of the intervertebral foramen = dumbbell shaped tumor.
- May be part of multiple neurofibromatosis = Von Reklenhousen disease.
Ganglioneuroma :
- A rather elongated soft tissue mass in comparison to the more circular shape of
Neurofibroma.
Neuroblastoma :
- May contain central spicules or a peripheral rim of calcification.
NB: Neurogenic tumors may involve the posterior ribs or adjacent thoracic vertebra.
The benign N. tumors can produce :
- Splaying of several posterior ribs. - Rib notching.
- A localized pressure erosion defect of one or two vertebral bodies.
The malignant N. tumors can produce :
- Bony destruction.
- Rapid increase in size of the mass. - Pleural effusion .
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2. Computed tomography :
- A solid mass of soft tissue attenuation, which may contain calcification and may
involve the adjacent bones.
3. Myelography :
- Can demonstrate intraspinal extension.
NB: MRI is superior > CT (better soft T contrast).
PARAVERTEBRAL LESIONS
Radiological features :
- An elougated or lobulated soft tissue shadow with a well defined outline, usually
projects on both sides of the posterior mediastinum.
- Involvement of adjacent thoracic vertebrae or intervertebral disc spaces.
DD :
1. Inflammatory lesion (narrow disc space, bone destruction).
2. Neoplastic lesion (only bone destruction).
HIATUS HERNIA
Presentation :
- Posterior mediastinal mass in asymptomatic elderly patient.
- Dyspnea, retrosternal chest pain and epigastric discomfort.
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Radiological features :
1. Plain :
- A round soft tissue mass containing an air fluid level directed behind ! heart.
- In 70% it lies to the left of midline in the posterior mediastinum.
2. Barium meal :
- Shows the stomach above the diaphragm and within chest.
OESOPHAGEAL LESIONS
Radiological features :
*Plain :
- Widening of the posterior mediastinum behind ! heart on the right extending
from the thoracic inlet to the diaphragm.
- An air fluid level in the superior part of the posterior mediastinum with non
homogenous mottled appearance of food particles mixed with air.
- No air in the fundus of stomach.
*Barium swallow :
- Confirms the diagnosis.
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BOCHDALEK HERNIA
Anatomy :
The foramen of Bochdalek is a persistent developmental defect in the
diaphragm posteriorly produced by a failure of the pleuro-peritoneal canal membrane
to fuse with the dorsal esophageal mesentery medially and the body wall laterally.
Presentation :
- Posterior mediastinal mass in asymptomatic adult patient.
- Acute respiratory distress in neonatal period.
Radiological features :
- About 90% of Bochdalek hernia occur in the left hemidiaphragm due to !
protective effect of liver on ! right .
1. Plain :
- Small hernia: usually contain retroperitoneal fat, kidney or spleen.
appears as a soft tissue mass posterior costophrenic angle.
- Large hernia:
* contains small or large bowel
* appears as multiple ring shadows in the chest due to air filled loops of
bowel.
* Displacement of the ! heart and mediastinum to the contralateral side.
* Ipsilateral lung is invariably hypoplastic.
2. Barium:
3. U/S
4. I.V. Urography :
Can also confirm diagnosis by showing liver, spleen or kidney above diaphragm.
NEUROENTERIC CYSTS
Etiology :
- Partial or complete persistence of neuroenteric canal + vert anomalies.
- Incomplete separation of foregut from the notocord in the embryonic life.
- The cysts are often connected to the spinal meninges and to ! G.I.T.
NB: Enteric cyst: Intestinal duplication cyst related to ! esophagus + no vertebral anomalies.
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Presentation :
- Respiratory distress or feeding difficulties in infants.
- Chest pain in young adult, if peptic ulceration occurs within it.
Radiological features :
1. Plain :
- A round or oval soft tissue mass in the posterior mediastinum between the
esophagus and the spine causing forward displacement of the esophagus.
- An air fluid level is present after rupture of an infected cyst in ! esophagus.
2. Computed tomography :
- A mass of soft tissue attenuation.
PNEUMOMEDIASTINUM
Acute mediastinitis :
- Chest pain + fever.
- Mediastinum is widened & edematous houtline.
- Pleural effusion.
- Occasionally abscess.
Mediastinal hemorrhage :
- Trauma
- Leaking aortic aneurysm.
- Plain: widened medistinum, spinal fracture, pneumo or hydrothorax.
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PNEUMONIAS
Pneumonia:
Infective consolidation of the lung (replacement of alveolar air by exudate).
(Pathogenic organism)
Pneumonitis :
General term= inflammatory reaction of the lung ± consolidation.
Alveolitis on interstitial pneumonitis:
Inflammatory process mainly affecting the alveolar wall.
Bronchopneumonia :
Multifocal (bronchocentric) infection based on the pulmonary lobule & spreads
along the bronchial axis.
I- Lobar pneumonia :
Pathology :
1. Unifocal. 2. Centered on distal air spaces (alveoli).
3. Rapid spread across the pores of khon uniform consolidation.
4. Spare distal airway.
Radiologically :
1. Homogenous non segmented consolidation.
2. As airways are not involved & remain patent, so there is no volume loss & air
bronchogram is common.
ACUTE PNEUMONIA
Etiology :
A. Bacterial causes :
1. Pneumococci (streptococcus pn). most common
2. Loss common :
- Staph. aureus.
- Gram -ve organisms.
a. Pseudomonas. d. Legionella pneumophilia.
b. Klebseilla Freidlenders. e. E coli & proteus.
c. Haemophlus influenza.
3.Anaerobic organisms.
B. Non bacterial causes :
- Mycoplasma pneumonia : most common.
- Viral eg influenza & varicella.
- Ricketsial pneumonia.
- Chlamydial pneumonia.
NB: All cause bronchopneumonia except Pneumococi (basal) & Klebseilla (apical) cause lobar
STAPHYLOCOCCUS PNEUMONA:
PDF :
1. Debilitated hospitalized patients.
2. Aspiration from URTI (common).
Radiologically :
- Consolidation is classically segmental & patchy at least initially but later
confluent & homogenous.
- Often, Multifocal & bilateral.
- volume loss is common.
- Air bronchogram is unusual.
Features of complication :
1. Due to strong tendency for necrosis that occur in the center of staph.
consolidation cavitation and abscess formation.
2. Rupture of cavity in pleura empyema.
3. Pneumatocele formation: Occurs when consolidation and fluid content of the
abscess cavity are resolved leaving thin hair-line walled air cavities, which
mainly persists for months or disappear leaving no trace.
4. Septicaemic staph pneumonia multifocal, nodular consolidation.
5. Collapse.
PSEUDOMONAS AERUGINOSA:
- Pulmonary infections follow mechanical ventilation or inhalation therapy
- Mainly affects the lower lobes and its radiological pattern is similar to staph
aureus infection.
H. INFLUENZA:
- Mainly associated with chronic lung disease is chronic bronchitis or secondary
invader in influenza virus infection.
- Has no characteristic radiographic pattern.
ANAEROBIC PNEUMONIA
Differs from other bacterial pneumonia in that :
1. Often clinically subacute or chronic with prominent systemic symptoms.
2. Results commonly from aspiration of infected oral contents.
Radiologically :
- Consolidation is uni or multifocal & tends to occupy segments favored by
aspiration eg (posterior upper / Apical lower/ postero basal), more on the RT
side.
- Homogenous, but usually cavitation lung abscess.
- Empyema is common bronchopleural fistula.
MYCOPLASMA PNEUMONIA:
Mycoplasma pneumoniae is an organism intermediate between bacteria and virus.
It is one of organisms produce primary atypical pneumonia which are:
Causes of primary atypical pneumonia :
1. Adenovirus. 4. Toxoplasma.
2. Psittacosis - Chlamydial 5. Mycoplasma
3. Q fever = Rickettsial.
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VIRAL PNEUMONIA:
- Common in infants and children.
- In adult, viral pneumonia may be primary as in influenza, or as a part of
generalized viral illness in varicella.
- Radiologically: wide spread nodules, interstitial streaks from hila, mediastinal &
hilar adenopathy.
INFLUENZAE
Predisposing Factors: old age, debilitated persons.
Radiologically :
- It begins a few days after the onset of symptoms.
- Extensive bilateral confluent consolidation which if patient survives, may be
be followed by fibrosis.
VARICELLA
Typically affecting young adults.
Predisposing f: Lymphoma, pregnancy.
Radiologically:
- Characteristically, widespread 5-10 mm nodules, which may simultaneously
come and go in different areas.
- Nodules, usually resolve in a week but it may persist.
- 20% of the opacities calcify.
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RICKETSIAL PNEUMONIA:
The most common ricketsial lung infection is Q fever, which is caused by coxiella
burnetti, which is mainly acquired from sheep and cattle.
Radiologically :
- One or more rounded segmental consolidations in the lower zone.
- Linear areas of collapse (common).
- Resolution mainly slow.
CHLAMYDIAL PNEUMONIA:
The commonest lung infection is ornilhosis caused by chlamydia Psittaci, which is
acquired from sick birds.
Radiologically :
- Variable pattern: lobar, patchy or miliary consolidation.
- Slow resolution.
A. Effusion: most common with anaerobes , gam-ve ligonella, staph & strept.
B. Empyema: staph aureus, strept, anaerobes
Rad: indistinguishable from effusion, suspected when large, delayed in app.,
unusual dist., or when associated with fluid level abscess.
C. Hydropneumothorax: Iatrogenic or rupture of pneumotocele or abscess or br.pl.
Fistula. (staph, gram-ve)
D. Localized transradiancies:
1. Abscess formation :
- Factors in favor : 1. Aspiration of infected material.
2. Infection by specific material.
3. Infection by anaerobic organisms.
- Abscess is within area of consolidation, communicates with airway & contents
are discharged with resultant air fluid level formation.
- Causes: A. Staph aureus :
* Usually multiple. * No lobar predilection
* Thick walled with raged inner lining.
* Associated with A, B, & C & pneumatoceles.
B. Tuberculosis.
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Pneumatocele :
Def.: cyst in lung during course of pneumonia (staph aureus).
Cause : tension cyst d.t partial obst. of small branches.
Site : in area of consolidation
Size : variable.
Shape : hair line wall - full of fluid.
Number : multiple or solitary.
Course : resolve.
Compl. : pneumonia + empyaema.
DD : hernia
Emphysematous bullae ( its wall is made of surrounding compressed lung tissue)
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RESOLUTION
90% of bacterial (except TB) and non bacterial pneumonias resolve within one month.
When changes persist beyond two months delayed resolution.
Causes of delayed resolution :
1. The commonest : old age, systemic disease.
2. Very extensive consolidation or complicated with cavitation, empyema or
atalectasis.
3. Presence of predisposing local cause e.g. bronchiectasis or air way obstruction.
4. Inappropriate therapy e.g. TB, mycosis.
5. Repeated aspiration: chronic sinusitis, achalasia or hiatus hernia.
N.B:
* Mendelson’s syndrome :
Chemical pneumonia, caused by aspiration of acid gastric contents during anesthesia
producing intense bronchospasm which is rapidly followed by pulmonary edema.
* Young’s syndrome :
Obstructive azospermia / Sinusitis / Chr. pulmonary infecting eg. bronchiectasis.
Pneumonias (KEY):
PDF/AGE/Complications A,B,C,D,E,F,G & resolution./Path & Rad.
Lobar BronchoPneumonia
1. Unifocal 1. Multifocal
2. Centered on air spaces 2. Centered on airways.
3. Khon consolidation 3. Spread along bronchial
4. Spare distal air ways 4. Airway obst.
↓ ↓
- Homogenous non seg Non homogenous, segmental (late confluece)
- No volume loss volume loss (atalectasis)
- Air bronchogram no air bronchogram
FUNGAL INFECTION
A. Pulmonary Histoplasmosis :
Caused by histoplasma capsulatum (soil dust)
1. Benign primary form :
- Initially, pulmn. focus is not identified & main sign is hilar or mediastinal
lymphadenopathy.
- With healing calcification of initial pulmn focus/ lymph nodes.
- Calcified LN may extend into! bronchi, where they are known as broncholiths
bronchial obst.
- In few cases: mediastinal fibrosis constriction of major Vs: SVC & pulmn.Vs
.
2. Chronic pulmonary form :
A. Histoplasma granuloma :
- Rounded nodule < 2cm.
- Usually well defined edges
- Irregular: difficult to distinguish from primary carcinoma.
- presence of central calcification is diagnostic.
B. Chronic fibrocavitary form :
- Indistinguishable from fibrocavitary TB.
B. Coccidioidomycosis :
Caused by coccidia fungus :
I. Patchy consolidation :
- Mainly lower lobes.
- Cavitation thin wall cavities (grape skin).
- Pleural effusion. / mediastinal LN.
II- Nodular form :
- Nodules (multiple or single) up to 3cm.
- Mainly upper lobes.
- Cavitation thin wall cavities (resembles TB) DD: miliary TB.
- Calcify.
- Rare : Miliary pattern due to blood dissemination.
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C. Actinomycosis :
- Commensal in oropharynx (normally):
Aspiration lower lobe pneumonia (dependant) abscess formation,
empyema, rib osteomylitis
- Sinuses open on skin yellow sulfur granules.
D. Aspergillosis :
Aspergillus fumigatus fungus. Three forms :
1. Pulmonary mycetoma (Aspergilloma)
- Here ! fungus is present as a saprophyte where ! fungal hyphae are matted
together in ! form of a ball in a pre existing lung cavity (eg TB, histoplasmosis,
Sarcoidosis, cong. lung cyst, cavitary bronchogenic carcinoma).
- Common in upper lobe.
- Mycetoma mainly doesn’t appear in CXR dt high opacity of fungus ball with
thickening of the adjacent pleura.
- Diagnosis is established by (CT, tomography) that reveales the fungus ball
delineated by a crescent of air (halo sign).
DD :
1. Blood clot in a cavity. 3. Simple lung abscess.
2. Cavitary sq. cell C. 4. Disintegrated hydatid cyst.
2. Invasive aspergillosis :
- Pneumonia in immunocompromised pt.
- No characteristic radiological pattern :
* Necrotizing bronchopneumonia with abscess formation.
* Single or multiple nodules (1-5cm) which may cavitate.
* Organizing lobar pneumonia.
* It can mimic with an aspergilloma ..... The difference is that it develops in
an apparently previously normal lung tissue.
3. Allergic, bronchopulmonary, aspergillosis :
- A hypersensitivity reaction, which occurs in ! major airways of some asthmatics.
- It is associated with blood eosinophillia, increased serum IgE, and +ve skin
reaction to aspergillus.
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Radiologically :
A. Acute changes :
- Consists of non segmental areas of consolidation, common upper lobe (loffler $).
- Lobar collapse.
- Branching thick tubular opacities due to distended bronchi with mucus and
fungus (bronchocele).
B. Chronic changes :
- Consists of bronchial wall thickening with tram line shadows.
- Ring formation indicative of bronchiectasis .
- Linear shadows indicative of fibrosis.
F. Blastomycosis :
- Asymptomatic nodule. - Chronic pneumonia.
- Potential for re-activation. - Node enlargement.
B. Schistosomiazis :
- Eggs lodge in small pulmn. Arteries (100 m) small granulomas like TB.
- If lodge in large arteries irritation vas. necrosis fibrotic occlusion
pulmn. hypertension (Ayerza dis).
- Diffuse interstitial fibrosis.
C. Protozoa :
1. Pleuropulmonary amoebiasis :
Usually secondary to liver amaebiasis, young adult male .
Radiologically:
- Elevation of hemidiaphragm, pleural effusion / or thickening.
- Basal band shadow (discoid atalectasis).
- When liver abscess erodes ! diaphragm basal non segmental consolidation
cavitates & fistulae develops between air way & pericardium.
- Blood spread consolidation or abscess in part away from ! diaphragm.
Diagnosis :
1. US liver.
2. Serological test.
3. Also aspiration biopsy guided by U/S is valuable.
2. Toxoplasmosis :
- Human acquisition is from cats.
- Presented as primary atypical pneumonia and mediastinal lymphadenopathy.
3. Pneumocystitis carinii infection :
Only expressed in immunocompromised patients.
Radiologically :
- Diffuse bilateral pulmonary opacification like pulmonary edema, homogenous
with air bronchogram.
- Focal emphysema may occur, where multiple air cysts with air fluid level may
be seen, which may complicate with pneumothorax and pneumomediastinum.
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D. Hydatid Disease :
Infection with the tape warm Echinococcus granuloses.
Radiologically :
The cyst is unilocular, smoothly spherical and of homogenous density,
calcification is rare.
Complication :
- Infection
- Rupture:
* into ! pleural cavity or a bronchus.
* Partial replacement of fluid by air (fluid level.)
* Rupture of a liver cyst into ! right lung produces a basal opacity from lobar
infection or atalectasis-pleural effusion.
TC99m labelled IDA hepatic defect.
Definition: a portion of the lung is separated from the normal bronchial tree & blood
supply, though retaining some characteristics of lung tissue.
Divisions :
1. Intralobar : lying within the lung, usually posteriorly in left lower lobe. Rt.
lower lobe is the next most common site.
Radiological appearance:
Plain:
* Soft tissue mass in posterior part of lower lobe close to the diaphragm
(> on lt.side).
* if connected to ! bronchial tree air containing cystic masses ± air fluid levels
(infection).
Bronchography:
* ?? c.m. rarely enters the lesion.
*Bronchial tree is spread around the mass & is typically complete with no of its
divisions.
Angiography:
* derives its bl. supply from ! descending thoracic aorta.
* venous drainage is via the pulmonary system or IVC.
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II. Extra lobar : The non-functioning portion of the lung (sequestrated portion)
develops enclosed in its own pleura.
It is much less common than intralobar sequestration & is interposed between inferior
surface of lt lower lobe & diaphragm + other congenital anomalies (found at autopsy).
Angiography:
* arterial supply is frequently from abdominal aorta.
* venous drainage is via IVC, azygous or portal venous system.
C/P : Recurrent infection in part of a lung with unusual abscess, cavity or cyst esp
at left lung base.
LUNG ABSCESS
(Localized suppurative inflammation of lung)
Complications :
Radiological features :
I. Abscess arising on cavitation of consolidation :
1. Consolidation : Primary Pn. or Secondary Pn. (br. obst).
2. Site : uncommon above clavicles.
3. Size : Rapid increase indicates air trapping tension cavity.
4. Shape:
- Air fluid level within lumen
- Inner lining : Shaggy smooth
- Wall : thick thin
5. Surrounding lung tissue :
- ↑ markings & patchy consolidation (inflam).
- ↑ lobe containing abscess→ bulging of fissures.
6. Fate : Resolution or lung damage (fibrosis & or bronchiectasis)
6. Caplan nodule.
DD: Lung cavities
1. Infective i.e Abscess
Staph / Klebsiella / TB /Aspiration / Gram-ve / Fungi / Hydatid
2. Neoplastic:
Carcinomas of bronchus / Metastases / Hodgkin
3. Vascular:
Infarction
4. Abnormal lung:
Cystic bronchiectasis / sequestrated segment / bronchogenic cyst
5. Granulomas:
Wegener’s granulomatosis /Rheumatoid nodules caplan / Progressive massive
fibrosis pneumoconiosis / Sarcoidosis.
6. Traumatic
Haematoma / Traumatic lung cyst
Tuberculosis
Body reactions :
I. Proliferative reaction Tubercle made of :
1. Macrophage phagocytose bacilli epithelioid cells.
2. Release of tuberculoprotein (cell mediated immune response) sensitized T-
lymphocytes.
3. Fusion of several epithelioid cells Langhan’s giant cells
* Caseation of tubercle center occurs by lymphokines
4. Lymphocytes & fibroblasts usually surround epitheloid cells.
Fate of tubercle
1. High immunity: complete fibrosis / fibrous capsule & central calcification.
2. Low immunity: fuse to form bigger tuberculous patch / spread (local,
lymphatic, blood. or natural passages).
Classification of TB:
I. Primary pulmonary TB: Ghon’s.
II. Post primary pulmonary TB: (reactivation or reinfection)
1. Chronic fibrocaseous TB.
2. Acute (Miliary TB of the lung / tuberculous bronchopneumonia)
Post Primary TB :
1. Early fluffy opacities.
2. Chronic active opacities + strands + cavities.
3. Old healed fibrosis + calcification.
Complications :
1. Haemoptysis, suppurative bronchitis.
2. Pleura pleurisy, empyema, pneumothorax.
3. TB heart & ribs Pulmonary hypertension HF.
4. Blood bone, brain, male & female genital
5. TB bronchopneumonia, laryngitis , tongue entritis.
6. Amyloidosis.