Radiology of Cough

Assistant professor Dr. Shawnm Nasih Dawood

College of medicine-Hawler Medical University
Radiology of Cough

Learning Objectives:
Student should be able to:
Recognize the imaging modalities used in cases of cough.
Recognize the imaging findings of certain respiratory diseases
causing cough.
 Case 1
A 35-year-old man presented with fever and productive cough for 3
days. He was febrile, hypoxic and physical examination showed
focal decrease in air entry and coarse crepitations over the right
upper chest. Laboratory investigations revealed leukocytosis and a
CXR was performed .

Questions:
(1) What abnormalities do you
see on this CXR ?
(2) What is the most likely diagnosis ?
 Case 2
A 45-year-old woman with poorly
controlled diabetes mellitus, presented
with productive cough for 1 month. She
also noticed low grade fever, night
sweating and weight loss during this
period. Examination of the chest
showed a dull percussion note,
decreased air entry and coarse
crepitations in the right upper zone.
Laboratory investigations revealed
raised ESR, normal white cell count and
a CXR was performed.
Questions:
(1) What radiological abnormalities can
you identify ?
(2) What is the radiological diagnosis ?
 Case 3
A 55-year-old non-smoker presented
with on and off haemoptysis and
purulent sputum for 1 year. There was
no fever or constitutional symptoms.
Physical examination showed finger
clubbing and coarse crepitations over
the lung base. Blood tests were
essentially normal and an initial CXR
was performed.

Questions:
(1) What abnormality can you see on
CXR ?
(2) What is the most likely diagnosis ?
 Case 4
15-year old boy
presented with cough
and dyspnea.

Questions:
1-What abnormality can
you see on CXR ?
2-What is the most likely
diagnosis ?
Plain X-rays
Although a routine chest X-ray won't reveal the most common
reasons for a cough — postnasal drip, acid reflux or asthma — it
may be used to check for lung cancer, pneumonia, and other
lung diseases.
An X-ray of the sinuses may reveal evidence of a sinus infection.
Computerized tomography (CT) scans
CT scan of chest
CT scan PNS also may be used to check sinus cavities for pockets
of infection.
 On a chest x-ray lung abnormalities will either present as
areas of increased density or as areas of decreased density.
 Lung abnormalities with an increased density - also called
opacities - are the most common.
 A practical approach is to divide these into four patterns:
1-Consolidation 2-Interstitial 3-Nodules or masses 4-Atelectasis
If there is an area of increased density within the lung, it must
be the result of one of these four patterns:
Consolidation - any pathologic process that fills the alveoli
with fluid, pus, blood, cells (including tumor cells) or other
substances resulting in lobar, diffuse or multifocal ill-defined
opacities.
Interstitial - involvement of the supporting tissue of the lung
parenchyma resulting in fine or coarse reticular opacities or
small nodules.
Nodule or mass - any space occupying lesion either solitary or
multiple.
Atelectasis - collapse of a part of the lung due to a decrease
in the amount of air in the alveoli resulting in volume loss and
increased density.
Chest conditions associated with cough

Pneumonias.
Lung abscess.
Pulmonary tuberculosis
Bronchiectasis.
Hydatid disease of the lungs.
Pneumonia or Pneumonitis is inflammation of the lung parenchyma. It
may be caused by infectious microorganisms e.g. bacteria, viruses and
fungi or non infectious agents like aspiration, hypersensitivity reactions,
and drug- or radiation-induced pneumonitis.

Etiology of infectious pneumonia:

• Neonates: usually bacterial e.g. group B streptococci, listeria and
E. coli.
• 1 month-4 year: mainly viral e.g. RSV, adenovirus, parainfluenza &
Influenza viruses. If bacterial : Streptococcus pneumonia, H.
influenza.
• > 5 years: mainly bacterial e.g. M. pneumoniae, S. pneumoniae,
Chlamydophila pneumoniae, H. influenzae. If viral: influenza
viruses, adenovirus, other respiratory viruses.

Radiology in pneumonia is important:

• To confirm the presence of pneumonia
• For the location & extent of the disease
• For following its course
• To detect complications
Radiological signs of pneumonia are:
In most cases different abnormalities can be identified on chest
films. The more common radiological findings include
segmental or lobar consolidations and interstitial lung disease.
Other less common radiological findings include mediastinal
lymphadenopathy, pleural effusion, and cavitation.

Consolidation is the result of replacement of air in the alveoli by

transudate, pus, blood, cells or other substances.
-Pneumonia is by far the most common cause of consolidation.
-The disease usually starts within the alveoli and spreads from
one alveolus to another.
-When it reaches a fissure the spread stops there.
Chest X-ray-findings of consolidation :
1-ill-defined homogeneous opacity obscuring vessels
2-Silhouette sign: loss of lung/soft tissue interface
3-Air-bronchogram
4-Extention to the pleura or fissure but not
crossing it
5-No volume loss.

Consolidation means loss of air+ normal volume

It could be:
a- complete
b- incomplete
Complete when all air –space are replaced & lead to a dense radio-
opacity (lobar).
Or it could be incomplete when only some of the alveoli are affected
and this leads to fine mottling or patchy opacity.
Classical Lobar Pneumonia:
• Inflammatory changes confined to a lobe
classically due to Streptococcus pneumoniae
• Lobar pneumonia is a localized infection of terminal
air space.
• Inflammatory edema spreads to adjacent lung by
terminal air ways & pore of Kohn & cause uniform
consolidation of all or part of a lobe.
• Consolidation may persist after patient symptoms
have improved .
• Resolution is usually complete .
• CT is not required for primary pneumonia but for
assessment of complications.
On radiographs:
1. A shadow (opacification) with ill-defined borders except when
limited by fissures, in which case the shadow has a well-defined edge,
and normal volume of affected part of the lung (lobe) is preserved.
 A few lobar pneumonias increase the volume of the affected lobe,
causing the adjacent fissures to bulge, this is classically seen in
Klebsiella pnemoniae pneumonia.

2-The silhouette sign,

namely loss of visualization of the
adjacent mediastinal or diaphragm
outline.
This sign is useful for localizing disease
from plain CXR.
 An intrathoracic lesion touching
a border of the heart, aorta or diaphragm
will obliterate that border on chest x-ray.
3- An air-bronchogram
Normally, it is not
possible to identify air
in the bronchi within
normally aerated lung
substance because the
walls of the bronchi
are too thin ,but if the
alveoli are filled with
fluid ,the air in the
bronchi contrasts with
the fluid in the lung;
this is clearly seen on
CT scan .
To utilize the silhouette sign you must know what
structures are adjacent to each silhouette

A: Ascending aorta

B: Left heart margin

C: Left diaphragm

D: Aortic knob

E: Right heart margin

F: Right diaphragm
 Silhouette Adjacent Lobe/Segment
Right diaphragm RLL/Basal segments

Right heart margin RML/Medial segment

Ascending aorta RUL/Anterior segment

Aortic knob LUL/Posterior segment

Left heart margin Lingula/Inferior segment

Descending aorta LLL/Superior and medial segments

Left diaphragm LLL/Basal segments

Classical Lobar Pneumonia:

a b c

The dense lobar consolidation at admission (a) shows some

initial aeration at 1 week(b), but little in the way of radiological
resolution, despite symptomatic improvement.
At 5 weeks(c), there is almost complete resolution of
consolidation.
Sputum culture confirmed Streptococcus pneumoniae with the
diagnosis of pneumococcal pneumonia.
Bronchopneumonia (lobular pneumonia)

Plain radiograph
 Multiple small nodular or
reticulonodular opacities
which tend to be patchy
and/or confluent. This
represents areas of the
lung where there are
patches of inflammation
separated by normal lung
parenchyma.
 The distribution is often
bilateral and asymmetric
and predominantly involves
the lung bases
Viral pneumonia
 Viral infection often starts in the
bronchi & bronchioles causing
bronchial wall thickening, and
extends into the interstitium
(interstitial pneumonia).
 Peribronchial shadowing
 Reticulonodular shadowing
 Patchy or extensive
consolidation
 In other cases such as
adenoviruses ,inflammation
may extend from bronchioles to
the alveoli &cause a
bronchopneumonia pattern .
These x-rays are of a patient with COVID-19.
On admission to the hospital the chest film was normal.
Four days later the patient is on mechanical ventilation and there are bilateral
consolidations on the chest film.
Chest-films can be useful in the follow-up of the disease.
Images of a 59 year old male who had fever for one week with non-
productive cough. The PCR-test was negative for COVID-19.
Because of clinical suspicion a CT was performed which showed some
areas of ground glass opacities and massive consolidation in the
posterior parts of the lower lobes (arrow on sagittal reconstruction).
Two days later a sputum test was positive.
Lung abscess
Lung abscess -Imaging Findings
On conventional radiography
• Usually single cavity
• Cavities typically have a
Thick-wall (which may become thinner as the surrounding inflammation
resolves)
Smooth inner margin
Air-fluid level
• More frequent in superior segments of lower lobes or posterior segments of
upper lobes
• Unlike pleural collections, lung abscesses frequently have a fluid level which
is approximately the same length on both the frontal and lateral projection
• About 1/3 may have an associated empyema
Lung abscess -Imaging Findings (cont.)

CT
• Helpful in differentiating between a lung abscess and an empyema
• Cavity may be seen as rounded with a thick wall and an air-fluid level
• Lung abscesses, being intraparanchymal, form an acute angle where
they meet the chest wall
Differential Diagnosis
• Cavitary bronchogenic carcinoma
• TB
• Multiple cavities point toward a necrotizing pneumonia more than lung
abscess
• Multiple cavitating masses point towards septic emboli
There is a thick-walled cavity (white arrow) There is a thick-walled cavity with a
with a smooth inner margin (red arrow), smooth inner margin (red and white
located in the right lung. arrows). An air-fluid level is present (black
An air-fluid level is present (black arrow). arrow).
 Pulmonary tuberculosis

 Pulmonary manifestations of tuberculosis are varied and

depend in part whether the infection is primary or post-primary.

 The lungs are the most common site of primary infection by

tuberculosis and are a major source of spread of the disease
and of individual morbidity and mortality.
Primary pulmonary tuberculosis
• The initial focus of infection can be located anywhere within the lung and has
non-specific appearances ranging from too small to be detectable, to patchy
areas or consolidation or even lobar consolidation.
• Cavitation is uncommon in primary TB, seen only in 10-30% of cases.
• In most cases, the infection becomes localized and a caseation granuloma
forms (tuberculoma) which usually eventually calcifies and is then known as
a Ghon lesion.
• The more striking finding, especially in children, is that of ipsilateral hilar and
contiguous mediastinal (paratracheal) lymphadenopathy, usually right sided.
• Pleural effusions are more frequent in adults.
• As the host mounts an appropriate immune response both the pulmonary
and nodal disease resolves.
• Healing by calcification.
• No fibrosis.
• A calcified primary complex remain visible through out life
Chest radiograph obtained in a 4-year-old girl shows isolated left hilar
lymphadenopathy (arrow) without associated parenchymal involvement.
Primary pulmonary tuberculosis (cont.)

Spread of primary infection:

1- the bronchial tree …….bronchopneumonia ,patchy,
lobar pneumonias may involve one or more lobes ,or
bilateral and frequently cavitate .
2- blood stream …….. miliary tuberculosis.
Miliary pulmonary tuberculosis

• Uncommon but carries a poor prognosis.

• It represents haematogenous dissemination of an
uncontrolled tuberculous infection.
• It is seen both in primary and post-primary
tuberculosis.
• Miliary deposits appear as 1-3 mm diameter nodules,
which are uniform in size and uniformly distributed.
• No fibrosis.
• No mediastinal lymph node enlargement
• With adequate treatment they slowly resolve
occasionally calcified
Miliary TB Chest X-ray and CT appearances
 Post-primary pulmonary tuberculosis
reactivation tuberculosis or secondary tuberculosis occurs years later,
frequently in the setting of a decreased immune status.
Lesions develop in either:
1.posterior segments of the upper lobes
2.superior segments of the lower lobes
• Typical appearance of post-primary TB is that of patchy consolidation or
poorly defined linear and nodular opacities.
• more likely to cavitate than primary infections.
• Endobronchial spread along nearby airways is a relatively common
finding, resulting in a relatively well-defined 2-4 mm nodules or
branching lesions tree-in-bud appearance on CT.
• Lobar consolidation, tuberculoma formation and miliary TB may occur.
• Pleural effusions, pleural thickening, pleural calcification.
• Mediastinal L.N. enlargement not occur.
• Tuberculous lesions caseate & may be calcified as they heal, Calcium is
laid down in the center of the lesion & calcification are irregular in size
& shape, grouped in clusters .it may seen as hair –like linear streaks
which represent distorted vascular shadows
Cavity
 may appear as area of translucency within
consolidation
 it appears in acute phase ,single or multiple, large or
small
 thin or thick wall
 cavity wall thickness 1-8mm
 sometimes fluid level is seen in the cavity.
Chest radiograph obtained in a 19-year-old woman shows a
large right-sided pleural effusion (curved arrows) associated
with right hilar lymphadenopathy (straight arrows).
The Tree-in-Bud Sign

CT shows ill-defined small nodules

adjacent to the peripheral
bronchovascular structures. This
pattern is called "tree in bud". It is
frequently found in atypical pulmonary
tuberculosis.
Healing of post-
primary
tuberculosis
occur by fibrosis
which leads to
contraction of
the lung &
displacement of
normal
landmarks .
Chest radiograph obtained in a 25-year-old Asian woman
shows volume loss of the right lung with mediastinal shift
to right. At bronchoscopy, severe stenosis of right main
and upper lobe bronchi was identified.
Tuberculomas
• account for only 5% of cases of post-primary TB
• appear as a well defined rounded mass typically located in the upper
lobes.
• they are usually single (80%) and can measure up to 4 cm in size.
• small satellite lesions are seen in most cases .
• superimposed cavitation may develop.
• Partially calcified and CT is needed to demonstrate the calcification.
Activity of the disease

1- Development of new
lesions or extension of
previous ones.
2- Demonstration of
thick-walled cavities.
Complications of pulmonary tuberculosis

Recognized complications include:

• aspergilloma
• bronchiectasis
• empyema - tuberculous empyema
• fibrothorax
• bronchopleural fistula
 Aspergillomas
Typically occur in the cavities of post-primary pulmonary
tuberculosis. Therefore, they are most frequently found in the
posterior segments of the upper lobes and the superior segments
of the lower lobes.
Radiographic features
 Can be seen on both plain film and CT
as an intracavitary mass surrounded
by a crescent of air.

 Calcification is not uncommon,

which can range from none to heavy.
This patient presented first with the CXR on the left.
The findings are:
Widespread ill-defined densities, which are probably small consolidations.
Cavity in the right upper lobe.
We can assume that this is reactivation of a latent TB.
Culture was positive for TB.
A CXR some years later on the right shows:
Right upper lobe atelectasis
Deviation of the trachea
Scarring and cavitation of the remnants of the upper lobe
In left upper lobe minimal fibrosis and cavitation.
Bilateral diaphragmatic
tenting. Note the triangular
opacities with its base on the
diaphragms. This is due to
pulmonary fibrosis.
What is pulmonary granuloma?
Granulomas are known to harbour tubercle bacilli. These bacilli are
dormant and may become re-activated anytime the patient‟s immunity
drops.

End on vessels can certainly mimic granuloma.

How do you tell the difference?
a.Granuloma is more likely if the „nodule‟
is in the upper zones or the outer 1/3 of
the lung fields
b. Granuloma is less likely if the „nodule‟
is in the medial 1/3 of the lung fields.
c. Granuloma is less likely if there is a
vascular structure leading to or adjacent
to the „nodule‟.
d. Granuloma is less likely if there is an
end-on bronchus next to it(appears as a
rounded hollow shadow).
e. Granuloma is more likely if the „nodule‟
is calcified.
bronchiectasis
Types of bronchiectasis

Cylindrical bronchiactasis:
Parallel lines representing the
bronchial walls radiating from
the hilum towards the
diaphragm.
Varicose type
Cystic bronchiactasis:
Cystic or ring shadows called
honeycomb appearance
sometimes with fluid levels.
Mixed type
 Radiological features:

The chest film may be entirely

normal .
Bronchiectasis is commonest at
the lung bases and a chest x-ray
may reveal the following
features:
1.“Tramlines” or “honeycombing”
represents dilated, thickened
bronchial walls
2. Volume loss due to destruction
of lung tissue
3. Multiple small nodular
densities from plugged alveoli
Tram-track sign may be used in chest radiography or CT to
denote the thickened non-tapering (parallel) walls
of cylindrical bronchiectasis.
CT scan in bronchiectasis
HRCT (High Resolution CT) is
diagnostic
• Signet ring sign is seen when the
dilated bronchus and
accompanying pulmonary
artery branch are seen in cross-
section. The bronchus and artery
should be the same size, whereas
in bronchiectasis, the bronchus is
markedly dilated.
• Lack of bronchial tapering
• Non uniform bronchial dilation
• Bronchial wall thickening
Bronchogram
Bronchograms are rarely done nowadays. The
need for it disappeared with the invention of
the fiberoptic bronchoscopy and high
resolution CT scan. View these images to get
a greater understanding of a three
dimensional view of a bronchial tree.
 Upper lobe bronchiectasis

• cystic fibrosis
• tuberculosis
Bronchiectasis-summary

• Chest x-ray is often normal, but can show thickened

bronchial walls, multiple cystic spaces with air-fluid
levels.

• Characteristic dilated bronchi can be demonstrated

with high resolution CT.

• Bronchogram is no longer necessary.

 Hydatid Disease of the lungs
 Involvement of the lungs produces chronic cough, dyspnea, pleuritic
chest pain, and hemoptysis.
 Radiographic features depends on whether is simple or complicated
cyst.
Simple Hydatid cyst
-one or more spherical or oval,
well-defined, smooth masses of
homogenous density usually in the middle
or lower zones.
-multiple cysts are seen in 1/3rd of patients
and are bilateral in 20% of patients.
-mostly lower lobes, the posterior
segments and the right lung.
Complicated Hydatid cyst that could be:
-infected cyst with the radiological features of a lung abscess.
-ruptured hydatid cyst.
Ruptured hydatid cyst

If the pericyst ruptures, air

dissecting between the
fibrotic lung forming the
pericyst and the ectocyst of
the parasite leads to a visible
crescent of air between the
two and is known as the
meniscus sign or crescent sign.
Ruptured Hydatid cyst (cont.)

 If the cyst itself

ruptures, an air-fluid
level results and
daughter cysts may
be seen floating in
residual fluid
 This pathognomic
appearance is
described
as water-lilly sign.
CT scanning in pulmonary hydatid
disease reveals :
-fluid content within the cyst with a density
close to that of water.
-At CT, the wall thickness ranges from 2mm
to 1cm.
-Daughter cysts, when present, appear as
curved septations as seen in the image
below(arrows).
Two images of the same patient

A B
 References

• Pellegrino, S., Mansi, L. Andrea Rockall, Andrew Hatrick, Peter

Armstrong, Martin Wastie (Eds.): Diagnostic Imaging (7th
edn.). Eur J Nucl Med Mol Imaging 41, 2357 (2014).
• Textbook of Radiology and Imaging -vol. 1-
7th edition-David Sutton
• https://radiologyassistant.nl/chest/chest-x-ray-lung-disease
• https://radiopaedia.org/
• https://www.radiologymasterclass.co.uk/