Question 1

You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has diffuse, confluent, fluffy-appearing disease, primarily in the lower lobes. The
disease silhouettes the normal shadows of the hemidiaphragms (black arrows). These are
characteristics of airspace disease. In an acute setting, this pattern is suggestive of
pulmonary edema, diffuse pneumonia, massive aspiration or extensive hemorrhage. This
patient was in pulmonary edema.

Patient B has multiple discrete, sharply marginated nodules in both lungs (white arrows).
The nodules are of varying size. This is interstitial lung disease and this pattern is most
commonly seen in metastatic disease to the lung. This patient had colo-rectal carcinoma.

Identification of the pattern of lung disease can help in directing the differential diagnosis.

Question 2
You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has interstitial disease in the form of a large mass in the right lower lobe (closed
black arrow). The border of the mass is sharp and there is a distinct margin between the
mass and the surrounding normal lung. This was a bronchogenic carcinoma.

Patient B has right lower lobe disease (broken black arrow) which is fluffy and poorly
marginated. It is difficult to tell with certainty where the disease ends and normal lung
begins. These are all characteristics of airspace disease. Patient B had aspiration pneumonia.

Question 3
 You are shown an image from chest CTs on two different patients - A and B.
Which of the statements describes the patterns of lung disease on each of these
two scans?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
The CT scan of patient A displays multiple black, branching structures (white arrows) that
represent air bronchograms. When something of fluid or soft tissue density fills the space
around the air-containing bronchi, the air within the bronchi becomes visible. An air
bronchogram is almost always a sign of airspace disease. This patient had right lower lobe
pneumonia.

Patient B has multiple sharply marginated nodules in both lungs (black arrows). The
nodules have lobulated contours but there is a clear demarcation between the nodules and
the surrounding normal lung. These are characteristics of interstitial lung disease. Multiple
lung nodules are most often blood-borne metastases. This patient had a primary renal cell
carcinoma.

Question 4
You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A’s chest radiograph displays diffuse reticular interstitial disease. There are multiple
“lines” throughout the lungs, many of them representing bronchi seen on-end or en face.
This patient had mucovicidosis (cystic fibrosis).

Patient B has a diffuse interstitial pattern that contains both “lines” (reticular) and “dots”
(nodules). This combination is called a reticulonodular pattern. There are many diseases
that can produce a diffuse reticulonodular pattern, ranging from sarcoidosis to metastases,
so history and clinical findings are key. This patient was HIV-positive and was febrile with
a cough. This was Pneumocystis carinii pneumonia (PCP).

Question 5
 You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A demonstrates two cardinal signs of airspace disease-the air bronchogram (closed
black arrows) and the silhouette sign (open black arrow). This right upper lobe pneumonia
is of fluid density and is in contact with the ascending aorta whose edge is no longer visible
because of the adjacent pneumonia.

Patient B demonstrates fluffy, confluent disease with indistinct margins (closed white
arrow) that silhouettes the left heart border identifying it as airspace disease in the lingular
portion of the left upper lobe. Patient B had a Pneumococcal pneumonia.

Question 6
You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has diffuse, fluffy and confluent disease with indistinct margins (black circle),
signs of airspace disease. The airspace disease has replaced the air normally found in the
lower lobes so that they are the same density as the heart and diaphragm. Thus the edges of
the heart and the hemidiaphragms are not visible (silhouette sign). This patient had
pulmonary edema.

Patient B has innumerable reticular densities scattered throughout both lungs. This is
reticular interstitial disease (white circle) such as might be seen with pulmonary fibrosis
(usual interstitial pneumonia), sarcoidosis, collagen vascular diseases and some
pneumoconioses. This patient had idiopathic pulmonary fibrosis.

Question 7
 You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has a mass in the left upper lobe (white arrow). It is sharply marginated and well-
circumscribed. The demarcation between the mass and normal lung is clear. It satisfies the
criteria for an interstitial process. This was a left upper lobe bronchogenic carcinoma which
was an adenocarcinoma in cell type.

Patient B has confluent airspace disease that occupies the whole upper lobe on the right. It
is homogeneous, lobar in distribution, sharply demarcated only where it contacts the minor
fissure (black arrow). There are air bronchograms present (black circle). This was
a Pneumococcal pneumonia.

Question 8
You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has focal, confluent airspace disease with indistinct margins (black circle)
producing a silhouette sign where it obscures the left heart border (closed black arrow). The
patient was coughing and febrile and had pneumonia in the lingular portion of the left upper
lobe.

Patient B has numerous small, punctate nodular densities scattered throughout both lungs
(white circle). Upon closer inspection, these small nodules are actually calcified and
represent granulomas. This patient had a history of chicken pox pneumonia several years
before this radiograph was exposed. This is the appearance of healed chicken pox
pneumonia. Histoplasmosis is another disease to consider when numerous calcified
granulomas are present.

Question 9
 You are shown an image from chest CTs on two different patients - A and B.
Which of the statements describes the patterns of lung disease on each of these
two scans?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has innumerable small nodules diffusely dispersed throughout both lungs (black
circles). This is interstitial disease and this pattern of small nodules is
called micronodular lung disease. Diseases that produce this pattern include miliary
tuberculosis, sarcoidosis, pneumoconiosis and, usually with larger nodules than this,
metastatic disease. This patient had miliary tuberculosis.

Patient B has unilateral interstitial disease, primarily reticular in nature (white circle). There
is a right pleural effusion present (black arrow). The unilateral nature of this disease should
raise the possibility of lymphatic spread of carcinoma to the lung. Primary tumors that do
this include breast, lung, stomach and pancreatic carcinoma. This patient had a primary lung
cancer.

Question 10
You are shown frontal radiographs on two different patients - A and B. Which of
the statements describes the patterns of lung disease on each of these two
radiographs?

 Patient A and Patient B both have airspace disease

 Patient A and Patient B both have interstitial disease
 Patient A has airspace disease but patient B has interstitial disease

 Patient A has interstitial disease but patient B has airspace disease

That's correct!
Patient A has diffuse interstitial disease that is primarily reticular in nature (black circle). Of
primary importance in formulating a differential diagnosis is the knowledge of how acute or
chronic the disease is. Comparing the current study to any prior examinations is extremely
important. This patient had a normal chest study done two weeks earlier and is now acutely
short of breath. That points to an acute process and this was pulmonary interstitial edema,
the precursor of pulmonary alveolar edema (Figs. 4-1A and 4-6A).

Patient B has a focal density in the right upper lobe with a fluffy appearance, air
bronchograms (black arrow) and indistinct margins (white circle), all characteristic of
airspace disease. This was a Staphylococcal pneumonia.