Pe d i a t r i c I m a g i n g • R ev i ew

Menashe et al.
Errors in Pediatric Chest Radiography

Pediatric Imaging
Review

Pediatric Chest Radiographs:

Common and Less Common Errors
Sarah J. Menashe1 OBJECTIVE. Radiographic imaging of the pediatric chest presents several unique challenges
Ramesh S. Iyer and nuances, stemming from congenital variants and pathologic processes specific to this popu-
Marguerite T. Parisi lation. Errors in interpretation may lead to inappropriate further imaging, incurring additional ra-
Randolph K. Otto diation exposure and cost, as well as psychologic effects on the patients and their families.
A. Luana Stanescu CONCLUSION. Here, we aim to highlight some common and less common pitfalls in
pediatric chest radiography, as well as some tools for avoiding potential mistakes.
Menashe SJ, Iyer RS, Parisi MT, Otto RK,
American Journal of Roentgenology 2016.207:903-911.

Stanescu AL s L. H. Garland noted in his for avoiding potential errors using an organ-

A presidential address at the 1949

meeting of the Radiological So-
ciety of North America, radio-
and case-based approach.

Keywords: chest radiographs, errors, pediatric
DOI:10.2214/AJR.16.16449
Received March 15, 2016; accepted without revision
April 1, 2016.
Based on a presentation at the ARRS 2015 Annual
Meeting, Toronto, ON, Canada.
1
All authors: Department of Radiology, Seattle Children’s
Hospital, 4800 Sand Point Way NE, MA.7.220, Seattle, WA
98105. Address c­ orrespondence to A. L. Stanescu
(stanescu@uw.edu).
AJR 2016; 207:903–911
0361–803X/16/2074–903
© American Roentgen Ray Society
graphs are a highly reliable diagnostic tool
as long as their findings are taken in the con-
text of the patient’s history, clinical symp-
toms, and laboratory data; when used alone,
their “reliability may be evanescent” [1]. Al-
though errors in diagnostic radiology have
been presented and debated frequently over
the past several decades, most of the litera-
ture is centered on the adult population [1–
4]. More recent publications have highlight-
ed the importance of addressing radiology
errors separately in the pediatric population,
where disease processes and imaging algo-
rithms are often vastly different from those
in the adult population [5]. Compounding
these differences is the fact that radiography
remains the mainstay of much of pediatric
imaging, and follow-up radiographs, addi-
tional projections, and further imaging with
cross-sectional modalities are not always
recommended or appropriate, particularly in
the age of ALARA (as low as reasonably
achievable). This is especially true within
pediatric thoracic imaging. The use of a sys-
tematic approach to image interpretation,
with an awareness of common errors and the
underlying root causes, can aid both the pe-
diatric and general radiologist in avoiding
such pitfalls and rendering accurate inter-
pretations. We aim to provide a pictorial re-
view of some of the more common and un-
usual hazards in chest radiography in
children and to present some tips and tricks
Mediastinum
The normal mediastinum can have a vari-
able appearance on radiographs, depending
on the patient’s age, developmental stage, and
health status and the anatomic variations of
the thymus [6]. Congenital or acquired le-
sions, cardiac and vascular malformations,
and procedural or surgical changes can add
an additional layer of heterogeneity to the me-
diastinal appearance [7, 8]. Although cross-
sectional imaging allows detailed assessment
of the mediastinum and its contents and may
ultimately be required in certain cases, these
modalities are infrequently used as first-line
imaging [6, 9, 10]. Accordingly, a thorough
understanding of mediastinal anatomy and its
appearance on pediatric radiography is para-
mount [11].
Case 1
A 9-month-old girl had a history of atrio-
ventricular septal defect. The patient under-
went surgical repair, which was complicated
by heart block requiring a permanent pace-
maker and warfarin therapy (Figs. 1A–1C).
Discussion—The thymus is usually large
and nearly fully developed at birth, increas-
ing in size during early infancy. The thymus
gradually involutes after the age of 2 years,
becoming difficult to visualize on radio-
graphs after the age of 8 years but remaining
visible on cross-sectional imaging. By adult-
hood, thymic tissue is largely replaced by fat,
though the underlying cortical and medul-

AJR:207, October 2016 903


lary tissue persists [12]. Located in the an-
terior mediastinum, the thymus overlies the
pericardium, left innominate vein, and tra-
chea. It extends superiorly to the level of the
inferior aspect of the thyroid and inferiorly
as far as the diaphragm, though thymic shape
and size vary greatly throughout life.
Typically, in infancy and early childhood,
the thymus will be depicted on radiographs
as a soft-tissue structure with some degree
of transparency, allowing the visualization
of the underlying pulmonary vasculature.
This feature is in contradistinction to dense
pulmonary opacities, such as atelectasis or
pneumonia. The borders are often lobular
and wavy along the anterior impression of
the ribs, reflecting the soft nature of the thy-
mic gland. A more triangular or sail shape
sharply demarcated inferiorly by the minor
fissure is possible as well (Fig. 1D). Inter-
estingly, because of its embryologic descent
along the thymopharyngeal duct, normal thy-
American Journal of Roentgenology 2016.207:903-911.
mic tissue can frequently be found in ectopic
locations, such as in the neck or submandib-
ular region [13]. Though current literature is
exploring the importance of the thymus’s im-
mune function later in life, it is important to
note that partial or total thymectomy is rou-
tinely performed during cardiac surgery to
allow greater access to the heart and great
vessels [12, 14, 15]. Knowledge of this is es-
sential when evaluating postoperative radio-
graphs of patients who have undergone car-
diac surgery, because changes or widening of
the mediastinum should not be attributed to
thymic shadow or rebound.
Teaching points—The thymus is frequent-
ly removed during cardiac surgery. Changes
in mediastinal contours in patients who have
undergone cardiac surgery should prompt
correlation with specific surgical details and,
potentially, further investigation with cross-
sectional imaging.
On chest radiographs obtained in infants,
the thymic gland is depicted as a lobulat-
ed, occasionally triangular-shaped, soft-tis-
sue density with some degree of transparen-
cy, which allows visualization of underlying
lung vessels.
Case 2
A 4-month-old boy presented with breath-
ing difficulties (Fig. 2).
Discussion—The formation of the aortic
arch and associated structures occurs during
the third week of fetal life [16]. In 1948, Ed-
wards [17] proposed a double aortic arch mod-
el of development. This schematic, now wide-
904 AJR:207, October 2016
Menashe et al.
ly accepted, consists of six primitive paired
arches that undergo formation and regression
in ordered succession, ultimately forming the
aorta and its branches. Incomplete or improp-
er formation or regression of these arches can
result in various anomalies, namely vascular
rings [17, 18]. Vascular rings are divided into
complete and incomplete forms according to
whether vascular structures completely en-
circle or just compress, respectively, the tra-
chea and esophagus. Complete ring anomalies,
which comprise most vascular rings, include
double aortic arch and right arch with aberrant
left subclavian artery. Anomalous innominate
artery, pulmonary artery sling, and left arch
with aberrant right subclavian artery are less
frequent and are considered incomplete rings
[18]. Though representing less than 1% of con-
genital heart anomalies, rings are commonly
symptomatic, clinically presenting with aerodi-
gestive issues related to esophageal or trache-
al compression, or both. Symptom severity is
largely related to the degree of tracheoesoph-
ageal constriction, and as such, more severe
anomalies tend to present earlier.
Chest radiographs are often the first imag-
ing study performed, where important clues
to the presence of a vascular ring may in-
clude a right aortic arch. Additionally, if the
trachea is midline, narrowed, or bowed ante-
riorly in a symptomatic patient, a ring should
be suspected. A fluoroscopic esophagram
will nicely reveal the presence of a vascular
ring, and although several of the more com-
mon forms of vascular rings have character-
istic findings, occasionally specific anatom-
ic variants require further evaluation with
cross-sectional imaging [19, 20].
Patients with a pulmonary artery sling,
in which the left pulmonary artery origi-
nates from the right pulmonary artery and
encircles the right mainstem bronchus in
its course, generally present early in life as
a result of severe respiratory distress [21].
Though this is primarily a manifestation of
bronchial compression, associated complete
cartilaginous tracheal rings and tracheal ste-
nosis are frequently contributing factors. As
noted already, radiographs in these patients
will nearly always display some abnormal-
ity, and evaluation for tracheal narrowing on
frontal view or anterior bowing of the tra-
chea with abnormal soft tissue between the
esophagus and the trachea on the lateral view
should suggest this diagnosis [22].
Teaching point—Assessment of the caliber
and position of the trachea, as well as the lat-
erality of the aortic arch, should be performed
on every radiograph of the pediatric chest.
These may be the first clues indicating the
presence of a vascular anomaly. Attention to
meticulous radiographic technique, including
adequate inspiratory effort and positioning, is
a crucial component of such evaluation.
Case 3
A 12-week-old boy presented to the emer-
gency department with unexplained bruis-
ing. A skeletal survey was obtained to evalu-
ate for nonaccidental trauma (Fig. 3).
Discussion—Though there are many
methods used to compartmentalize the me-
diastinum, the divisions are theoretic rather
than truly physical, meaning that disease can
spread from one space to another and some
diseases can occur in more than one com-
partment. A three-part model that comprises
the anterior, middle, and posterior compart-
ments is useful when encountering a medi-
astinal mass on imaging [11]. The anterior
mediastinum, the most common site of me-
diastinal masses in children, is bordered an-
teriorly by the sternum and posteriorly by the
pericardium and contains the thymus and
prevascular lymph nodes. The most common
masses in this region are related to the thy-
mus, lymph node disorders such as lympho-
ma, and germ cell tumors. The middle medi-
astinum extends anteriorly from the anterior
pericardium to an imaginary line 1 cm pos-
terior to the anterior border of the vertebral
bodies. This space contains the heart, esoph-
agus, trachea, lymph nodes, and multiple
vessels and nerves. There is a wide variety of
potential lesions, though nonvascular masses
are most commonly related to foregut dupli-
cation cysts or lymphadenopathy. The poste-
rior mediastinum, bordered anteriorly by the
aforementioned imaginary line and poste-
riorly by paravertebral gutters, gives rise to
about a third of mediastinal masses. Though
these can include structural entities, such
as hiatal hernias or aortic aneurysms, most
of these lesions (nearly 90%) are neurogen-
ic in origin. They can arise from either the
paravertebral sympathetic chain (e.g., neuro-
blastoma, ganglioneuroma, and ganglioneu-
roblastoma) or the nerve sheath (e.g., schwan-
noma and neurofibroma) [11, 23] (Table 1).
Neuroblastoma is the most common solid
extracranial malignancy of childhood. It has
no sex predilection and is primarily a diagno-
sis of young children, because approximately
80% of them are present by the age of 4 years
[24, 25]. Neuroblastomas are tumors of neu-
ral crest origin and frequently arise in the ad-

TABLE 1: Differential Diagnosis for Mediastinal Masses by Compartment
Anterior
Normal thymus (mimic, most common “mass”)
Lymphoma (most common pathologic abnormality)
Germ cell tumor
Thymic cyst (rare)
Thymoma (rare in children)
renal gland (35%) or retroperitoneum (30%);
however, other possible sites of disease in-
clude the mediastinum (19%), neck (1%), and
pelvis (1%) [25, 26]. The often enigmatic pre-
sentation of these tumors lies in the variable
sites of origin, as well as the extent of meta-
static disease and presence of paraneoplas-
tic syndromes at presentation [27]. Though
complete workup invariably includes cross-
sectional and metaiodobenzylguanidine im-
aging, it is important to recognize that initial
American Journal of Roentgenology 2016.207:903-911.
diagnosis on radiograph is possible. Accord-
ingly, findings on radiographs of a well-cir-
cumscribed posterior mediastinal or paraspi-
nal mass associated with calcifications, rib
widening, or bony erosion, even in patients
being evaluated for seemingly noncontribu-
tory reasons, should raise high suspicion of
this entity and prompt further investigation
[25, 28, 29].
Teaching points—The thoracic paraspinal
lines should be thin on every projection. If
a posterior mediastinal mass is detected in
a young child, it should be considered neu-
roblastoma until proven otherwise. Neu-
roblastoma has a wide variety of clinical
manifestations, particularly in the setting of
metastatic disease, some of which can mimic
nonaccidental trauma.
Case 4
A 3-year-old boy was in distress after tra-
cheostomy tube placement (Fig. 4).
Discussion—Barotrauma or surgical in-
tervention in the neonate often results in
abnormal collections of air outside of lung
parenchyma, namely pneumothoraces and
pulmonary interstitial emphysema. Pneumo-
mediastinum is less common, particularly
when it is confined to the posterior compart-
ment, where air collects in the infraaortic
and infraazygous spaces [30]. When the im-
aging finding is large, it has been termed a
“vanishing heart,” because the cardiac shad-
ow becomes lost behind the lucency of the air
collection [31]. Recognition and timely diag-
nosis are important because, left untreated,
AJR:207, October 2016 905
Errors in Pediatric Chest Radiography
Middle
Lymphoma Neurogenic tumor, such as neuroblastoma (most common)
Lymphadenopathy Lymphoma
Foregut duplication cyst
Vascular malformation Nerve sheath tumor
this can lead to tension pneumomediastinum,
cardiac tamponade, and even death [31, 32].
Teaching point—Abnormal lucency over
the heart shadow over time has been termed
the vanishing heart and is a sign of posterior
pneumomediastinum.
Lungs and Pleura
Adequate radiographic evaluation of the
lungs is subject to technique and patient co-
operation, two factors that are not easily con-
trolled in pediatric imaging [33]. Tube angle,
patient rotation, level of inspiration, and tube
voltage settings can obfuscate true findings
or create false abnormalities when not opti-
mally managed. Ultrasound evaluation of the
lungs and pleura represents a useful adjunct,
particularly given the absence of ionizing ra-
diation, but it comes with its own limitations
of sonographer expertise and clinician com-
fort [6, 9, 34]. In many instances, contrast-en-
hanced CT is warranted.
Case 5
An 8-year-old girl had worsening fever in
the setting of known pneumonia and empy-
ema (Fig. 5).
Discussion—Cystic or cavitary lesions of
the lung can have a wide variety of causes in
the pediatric population and may be the result
of congenital lesions (e.g., bronchopulmona-
ry malformations, congenital lobar overin-
flation, or pleuropulmonary blastoma type I
and type II), chronic lung diseases (e.g., pul-
monary Langerhans cell histiocytosis), infec-
tious entities, or traumatic pseudocysts. In all
of these disease processes, imaging plays an
important role and often begins with a chest
radiograph [35].
When encountering a lucent lesion of the
lung, clinical history can be invaluable. The
patient in case 5 presented with community-
acquired pneumonia, one of the most com-
mon causes of pediatric hospitalization, af-
fecting 3–4% of the pediatric population.
Though pneumonia often responds well to
conventional treatment, complications such
Posterior
as empyema, lung necrosis, and broncho-
pleural fistula may occur [36, 37]. Despite
the significant morbidity associated with
these complications, radiographic findings
can be subtle. However, in the presence of a
dense consolidation, a focal lucency should
suggest underlying parenchymal necrosis,
whereas a newly developed pneumothorax
should raise suspicion of a bronchopulmona-
ry fistula. In the presence of these findings,
or if indeed clinical suspicion is high, ultra-
sound has been found to be an effective non-
ionizing alternative to CT diagnosis of nec-
rotizing pneumonia [36, 38].
Teaching point—New lucency present
within densely consolidated lung should raise
suspicion of pulmonary necrosis. This can be
confirmed with cross-sectional imaging.
Case 6
A 21-day-old boy with prenatally diag-
nosed lung mass presented for follow-up
(Fig. 6).
Discussion—Congenital lung malforma-
tions are rare, encompassing congenital pul-
monary airway malformations, congenital
lobar overinflation, foregut duplication cysts,
bronchopulmonary sequestration, hypoge-
netic lung syndrome, and even some vascu-
lar malformations [39, 40]. The pathogenesis
of these lesions is not fully understood, al-
though the presence of hybrid lesions (typi-
cally incorporating elements of both congen-
ital pulmonary airway malformations and
sequestration) suggests a common embryo-
logic origin [41].
When a pulmonary malformation is de-
tected prenatally, the high positive predictive
value of ultrasound warrants postnatal con-
firmation, even if prenatal ultrasound reveals
partial or complete regression [42]. Neonates
can present with respiratory distress, where-
as older children and adults may have recur-
rent infections. Radiographic findings, when
present, may include focal airspace opacity,
focal lucent lesion, or both [35]. If the pulmo-
nary malformation is large, this may result in

mediastinal shift or abnormal development of
the lungs. However, smaller congenital lung
lesions are often misdiagnosed or missed en-
tirely on radiographs, even with known pre-
natal history, and indeed some authors think
that radiographs are “hopelessly insensitive”
[39, 43]. As such, it is thought that any pre-
natally diagnosed lung mass should be fol-
lowed postnatally with a CT angiogram [39],
improving detection of subtle yet clinically
relevant imaging features, such as cystic or
solid components, precise anatomic location,
and mapping of any associated anomalous
vascular supply.
Teaching point—Prenatally detected lung
masses should be followed postnatally with
radiographs and ultimately with contrast-en-
hanced CT.
Bones
Radiographs of neonates are most com-
monly obtained for evaluation of the respira-
American Journal of Roentgenology 2016.207:903-911.
tory and gastrointestinal systems [44]. How-
ever, careful evaluation of osseous structures
can often yield clinically valuable informa-
tion. Incidental bony findings of osteope-
nia, fractures, or periosteal reaction are often
subtle but can suggest underlying metabolic
bone disease, congenital or neonatal infec-
tion, nonaccidental trauma, or therapy-relat-
ed changes [45, 46]. Congenital or inherited
bony diseases may be manifest on these ra-
diographs as well, with abnormal shape or
mineralization of some or all of the visual-
ized bony structures [47]. Careful attention
to and documentation of bony findings, com-
munication with the clinical team, and corre-
lation with pertinent patient history are para-
mount for correct diagnosis and appropriate
clinical management [48].
Case 7
A 9-week-old boy who had been born pre-
maturely presented with respiratory distress
and underwent serial chest radiographs (Fig. 7).
Discussion—Reduced bone mineral con-
tent in the premature infant, also known as
metabolic bone disease of prematurity, os-
teopenia of prematurity, or neonatal rickets,
can affect the strength and structure of the
skeletal system throughout life. Its frequen-
cy is increasing, predominantly as the result
of increased survival of premature infants,
who do not benefit from the final weeks of
in utero mineralization in the third trimester
of pregnancy. Additional risk factors include
long-term parenteral nutrition, low gestation-
al birth weight, and diuretic use, as well as an
906 AJR:207, October 2016
Menashe et al.
inadequate intake of calcium, phosphorous,
and vitamin D. Screening is an essential part
of adequate treatment and is usually prompt-
ed by specific clinical, radiologic, and bio-
chemical criteria [46].
Radiographic findings manifest late in
the disease process, because there must be
significant bone loss before it becomes ra-
diographically apparent. However, decreased
bony mineralization as evidenced by corti-
cal thinning and fractures may be seen. If
additional findings of robust subperiosteal
new bone formation, epiphyseal separation,
and metaphyseal abnormalities are present,
copper deficiency should be a differential
consideration. Although it is less common
overall, copper deficiency occurs in similar
pediatric populations, often in infants with
the added history of receiving total parenter-
al nutrition for a significant duration or those
with enteral diseases, such as short gut. Ad-
ditional hematopoietic abnormalities may
also be present [46, 49–51].
Teaching point—Bony demineralization in
the premature infant is an important observa-
tion that suggests underlying metabolic bone
disease of prematurity. Look for cortical thin-
ning and possible associated fractures.
Case 8
A 6-week-old boy had ductus-dependent
congenital heart disease (Fig. 8).
Discussion—The periosteal membrane
covers cortical bone, sparing only the artic-
ular surface, and is highly active in infants.
Periostitis can occur physiologically in the
first 6 months of life, usually around age 12
weeks. However, exuberant periosteal reac-
tion can also represent a manifestation of
numerous underlying pathologic abnormal-
ities, including hypervitaminosis A, scur-
vy, Caffey disease (infant cortical hyperos-
tosis), rickets, child abuse or other trauma,
malignancy, and acquired or congenital in-
fections (e.g., syphilis) [48]. Clinical history
and patterns of periostitis can offer impor-
tant clues to the underlying diagnosis. In-
volvement of a single bone suggests trauma,
infection, or tumor and should be correlat-
ed with trauma history or elevated tumor or
inflammatory markers, respectively. In the
setting of vitamin abnormalities, radiolog-
ic findings may be more diffuse and wide-
spread; laboratory values should help deter-
mine vitamin toxicity or inadequate intake.
Caffey disease typically involves the man-
dible on radiographs and may be associated
with hyperirritability, limb pain, and swell-
ing but also with thrombocytopenia and el-
evated inflammatory markers [52]. With
long-term prostaglandin-induced perios-
titis, which is most commonly seen in pa-
tients with cyanotic heart disease in whom
maintaining a ductus arteriosus is neces-
sary for survival, there is frequently a clini-
cal picture of limb pain and swelling. On
radiographs, however, periosteal reaction
is typically symmetric, single-layer, and
mainly involves the long bones, though the
ribs, clavicles, and scapulae can also be af-
fected [53–55]. Cessation of prostaglandin
therapy results in fairly rapid improvement
in the periostitis; however, it is important to
note that complete resolution can take up to
a year [53, 55].
Teaching point—Periostitis in the neonate
and infant may be physiologic, but can also
be a sign of underlying disease. Evaluating
the pattern and extent of bony involvement
and correlating with important clinical and
biochemical markers can suggest the under-
lying diagnosis.
Case 9
A 5-month-old boy presented with vomit-
ing (Fig. 9).
Discussion—As illustrated by Lachman
and Taybi [56], there is a vast array of dis-
ease processes that affect the appearance of
the skeletal system. Although the list is too
encyclopedic to commit to memory, recog-
nizing a few of the more common disorders
is helpful, and, in many instances, key radio-
graphic observations can lead the radiologist
to the correct diagnosis [57].
Hurler syndrome, or mucopolysaccharido-
sis type IH, is one of many types of muco-
polysaccharidoses, a varied group of inher-
ited lysosomal storage disorders occurring in
1 in 25,000 live births [58]. Although clin-
ical manifestations vary among each type,
typical findings include dysostosis multiplex
(discussed in the next paragraph), significant
CNS abnormalities, developmental delay,
and organomegaly [58].
In patients with Hurler syndrome, skele-
tal survey may reveal wide oar-shaped ribs
with anterior splaying, gibbus deformity with
kyphosis, dysplastic vertebrae with anterior
beaking, flaring of the iliac wings and hip
dysplasia, widening and shortening of the
distal bones of the extremities, and bullet-
shaped phalanges. These patients may have
atlantoaxial instability with spinal cord com-
pression, hydrocephalus, and closed enceph-
aloceles; therefore, neuroimaging is often re-

quired. Recognition and detailed evaluation
of the radiographic and neuroimaging find-
ings are invaluable for clinical planning and
management [58–60].
Teaching point—Recognizing and clas-
sifying bony abnormalities on radiographs
can provide key information for diagnosing
a skeletal dysplasia or syndrome. When sus-
pected, a skeletal survey and established ref-
erence material can be invaluable.
Conclusion
Radiography remains the workhorse of 14. Afifi A, Raja SG, Pennington DJ, Tsang VT. For
pediatric imaging, particularly of the chest.
It is rife with opportunities for error, because
cooperation and positioning are often chal-
lenging for such patients. Having a thorough
understanding of normal pediatric anatomy 15. Halnon NJ, Cooper P, Chen DY, Boechat
and developmental changes and a good com-
mand of entities unique to children is essen-
tial for the pediatric and general radiologist
to avoid significant interpretive errors.
American Journal of Roentgenology 2016.207:903-911.
Acknowledgment
We acknowledge the important contribu-
tion of Edward Weinberger to this manuscript. 17. Edwards JE. Anomalies of the derivatives of the
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A B

Fig. 1—Chest radiographs of two different patients.

A–C, 9-month-old girl with history of atrioventricular
septal defect who underwent repair and heart
block requiring permanent pacemaker, now
receiving warfarin. Initial chest radiograph obtained
immediately after surgery (A) shows normal contour
of superior mediastinum. Follow-up chest radiograph
obtained because of increased irritability 9 days
later (B) reveals new density with convex border
along left superior mediastinum (arrows, B), thought
to represent thymic shadow or rebound. If available
operative report had been reviewed, it would have
been known that thymus was removed at time of
cardiac surgery, as commonly occurs, and that
contour abnormality actually represented large
mediastinal hematoma (arrows, C) as seen on coronal
contrast-enhanced CT (C).
D, 3-month-old girl with cough. Chest radiograph
shows triangular-shaped right thymic lobe with sail
sign. Patient is rotated to right.
C D

908 AJR:207, October 2016

 Errors in Pediatric Chest Radiography

A B C
Fig. 2—4-month-old boy with breathing difficulty.
A and B, Frontal (A) and lateral (B) chest radiographs show diffuse narrowing of intrathoracic trachea (arrows, A) and subtle anterior displacement of inferior trachea
(arrows, B) by soft-tissue density (asterisk, B) interposed between trachea and esophagus. These findings were not described on report.
C, Three-dimensional reformat from CT performed 2 weeks later shows left pulmonary artery sling and diffusely narrowed trachea (arrows) secondary to complete
tracheal rings, which are commonly associated with this type of vascular ring.
American Journal of Roentgenology 2016.207:903-911.

Fig. 3—12-week-old boy with bruising.

A, Oblique chest radiograph from skeletal survey
for nonaccidental trauma shows right posterior
mediastinal mass (arrows) that was initially missed.
Per protocol, survey was repeated 1 week later and
mass was detected at that time; subsequent workup
revealed metastatic neuroblastoma. “Bruising” was
due to subcutaneous metastases (i.e., blueberry
muffin baby).
B, Coronal STIR MRI best defines right paraspinal
mass (arrows).
A B

AJR:207, October 2016 909

 Menashe et al.

A B C
Fig. 4—3-year-old boy who was in distress after tracheostomy replacement.
A, Large posterior pneumomediastinum (arrows) seen on initial supine frontal chest radiograph was misinterpreted as hiatal hernia. Subcutaneous emphysema, best
seen in left cervical area (arrowhead), was not described on report.
B and C, Frontal (B) and lateral (C) chest radiographs obtained few hours later show progressive worsening of pneumomediastinum (arrows) and subcutaneous
emphysema (arrowheads). Ultimately, tracheostomy site leak was diagnosed.
American Journal of Roentgenology 2016.207:903-911.

Fig. 5—8-year-old girl with pneumonia, empyema,

and worsening fever.
A and B, Lucent lesions seen on chest radiograph
in retrocardiac region (arrows, A), consistent with
necrotizing pneumonia as proven on follow-up CT
examination (arrows, B), were not mentioned in report.

A B

A B C
Fig. 6—21-day-old boy with lung mass noted on prenatal imaging.
A, Chest radiograph was read as normal. Ill-defined patchy densities in right lower lobe (arrows) were missed.
B and C, Coronal images from subsequent contrast-enhanced CT show mixed solid and cystic mass in posterior aspect of right lower lobe (B) with systemic arterial
supply (arrow, C), compatible with combined sequestration and congenital pulmonary airway malformation lesion.

910 AJR:207, October 2016

 Errors in Pediatric Chest Radiography

Fig. 7—9-week-old prematurely born boy with

respiratory distress.
A, Proximal right humeral fracture (arrow) seen on
frontal chest radiograph was not described in report.
B, Follow-up radiograph obtained 3 weeks later
shows exuberant callus formation at fracture site
(arrows). Finding is likely related to underlying
metabolic bone disease of prematurity.

A B
American Journal of Roentgenology 2016.207:903-911.

Fig. 8—6-week-old boy with congenital heart disease and dextrocardia. Diffuse symmetric periosteal reaction
from prostaglandin treatment in this patient with ductal-dependent congenital heart disease, seen along right
humeral shaft and partially visualized along left humerus (arrows), was not described on report for this frontal
chest radiograph. Physiologic mechanism is down-regulation of osteoclastic activity, with net osteoblastic
activity.

Fig. 9—5-month-old boy with vomiting.

A, Gibbous deformity at L1–2 secondary to inferior
beaking of L2 and L3 on lateral chest and abdominal
radiograph (arrows) were thought to be normal
variant.
B, However, these findings, combined with ribs being
wider than intercostal spaces, are highly suggestive
of Hurler syndrome, mucopolysaccharidosis type
IH. Diagnosis was suspected clinically at 10 months
(because of cloudy corneas) and was confirmed
biochemically.
A B

AJR:207, October 2016 911