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chest

Chest Cases:

Lung Parenchyma Cases

Scheme for the allocation of infiltrates to the segments of the right and left lung respectively; each takes up half a page - well suited for the reporting cabinet.

Silhouette sign: "An intrathoracic lesion touching a border of the heart or aorta will obliterate that border on the roentgenogram; an intrathoracic lesion not anatomical contiguous with a border of the heart or aorta will not obliterate the border" (Felson, 1973). Thus if a consolidation cannot be distinguished from the heart, it must be situated in the ventral lower thorax space, probably in the middle lobe or in the lingula. If the consolidation is definable in the heart shadow however, it is situated (anterior or) posterior to the heart (most probably in the lower lobe, as there is little space anterior to the heart).

Chronic Bronchitis

Dirty chest. Because of recurrent infection with scarring, the bronchovascular structures have irregular contours. This is the only sign of bronchitis in chest x-ray.

Chronic Bronchitis. The magnified view shows the irregular bronchovascular structures (arrow heads).

Chronic Bronchitis. Chest film and magnified view of right midfield. Irregular bronchovascular markings due to recurrent inflammation with scirrous deformation.

Chronic bronchitis. Chest film and magnified view on the right. The lines that leave the right hilum horizontally show irregular borders because of chronic inflammation.

Chronic Bronchitis. Chest film and magnified view from left upper field. On the right the upper part of the enlarged view shows irregular bronchovascular structures with variable diameters.

Chronic Bronchitis. Chest film and magnified view. The bronchovascular structures have an irregular appearance.

Chronic Bronchitis. Chest film and magnified view from the left periphery. The line that runs cranio-caudal is the medial border of the scapula. Arrowheads point to irregular pattern of bronchovascular structures.

Chronic Bronchitis. Chest film and magnified view from right middle/upper lung field. Irregular contours of bronchovascular structures with irregular diameters.

Alveolar infiltrate

An alveolar exudate is propagated via the pores of Kohn (and Lambert channels). Only the fissures limit the interalveolar propagation.

Infiltration in RUL with tree-in-bud sign. The small densities might be induced by inflammation like tuberculosis, or by a tumor.

Pattern of alveolar infiltrate, acute, with confluent small ill-defined densities, and after healing.

Pattern of alveolar infiltrate, magnified view. Confluent small ill-defined densities produce a reticular pattern.

A segmental pneumonia of s9 of right lower lobe shows alveolar densities.

Alveolar infiltration in the left lower lobe.

From alveolar infiltration to lobar pneumonia. There are coarse ill-shaped ("bronchopneumonic") densities in the lower part of the left lung. CT of the same day shows them as small crowdes nodules in an "alveolar" pattern. One day later (lower image on the right) the alveolar pattern has consolidated to a segmental density. (The patient has been treated in hospital because of a recurrent right sided pneumoserothorax).

Alveolitis of unknown origin. CT, magnified view. Low contrast nodules that are arranged along bronchovascular structures like buds on a tree. (2a): 5mm thick slices, (2b): HRCT, slice thickness 1mm.

Lobar pneumonia

RUL (right upper lobe)

middle lobe

RLL (right lower lobe)

LUL (left upper lobe)

lingula

LLL (left lower lobe)

Klebsiella pneumonia in the right upper lobe (RUL) with cavities.

Lobar pneumonia of RUL. The volume of the upper lobe is reduced (actually typical of an atelectasis) Consequently the minor fissure shows a convexity towards the upper lobe.

Lobar pneumonia of RUL.

Lobar pneumonia of RUL. Chest film a.p. and lateral view.

Lobar pneumonia of the 3rd segment of RUL. The fact that the upper lobe is involved can be deduced from the p.a. projection. The segment allocation in reference to the fissure results from the lateral projection.

Chronic infiltrate of unknown cause in RUL. Follow up over 4 months. The upper lobe shrinks increasingly. Thus the minor fissure rises with convexity.

Infiltrate in the anterior (2.) upper lobe segment on the right with positive bronchograms. The minor fissure is actually shifted to the infected lobe (this contradicts the rule that inflammation causes an increased volume). In addition a consolidation of the 6th (apical) segment of the lower lobe exists on the right. This can be recognized from the decreased transparency in p.a. film caudal of the consolidated upper lobe. In the lateral film it is visible in projection to the spinal column.

Infiltrate in the 2nd segment of RUL, and in the middle lobe, 5th segment. Supine film.

Segmental consolidation in RUL. Chest film and magnified view.

Middle lobe pneumonia. p.a. and lateral films.

Infiltrate in 8th segment of right lower lobe (RLL).

Follow up of lobar pneumonia in 10th segment of RLL.

Lobar pneumonia of RLL.

Lobar pneumonia of RLL. The comparison with the status after recuperation 2 weeks later explains the very discrete findings.

Lobar pneumonia of RLL.

Follow up of lobar pneumonia in the RLL. Because of the sharp cranial demarcation one might assume a middle lobe infiltration. The lateral view demonstrates the lower lobe localization.

RLL pneumonia, follow up. Supine films. Reduction of homogeneous consolidation with bronchograms in the process.

Follow-up of consolidation of anterior segment of left upper lobe (LUL).

Infiltration of 3rd left segment, LUL. Notice the different configuration of the segment in comparison to the preceding image.

Perihilar consolidation in LUL, follow up. Chest films, magnified views.

Infiltration of lingula. Chest films p.a. and lateral.

Pneumococcus pneumonia of s6 of left lower lobe (LLL). Cavitation with air fluid level (arrows).

Follow up of lobar pneumonia in 6th segment, LLL.

Lobar pneumonia in s6, LLL.

Lobar pneumonia in 8th and 9th left segments, LLL. a.p. and lateral chest films.

Lobar pneumonia of left 9th and 10th segments, LLL. In an underexposed film these segments are hidden in the heart shadow. Only the lateral projections show them. Usually one can discern the infiltration marks through the shadow of the heart. Especially digital radiography with its greater compliance with exposure differences makes this possible.

The consolidations might be completely hidden behind the heart on supine films. In such a case, elevation of the left side of the patient might improve the visualization.

Bronchopneumonia

Bronchopneumonia of both posterior lower lobe segments before (above) and during acute illness (below).

Bronchopneumonia in right middle and lower lung fields, on admission and after recuperation (left to right).

Bronchopneumonia of the right lung.

Bilateral bronchopneumonia. Supine film. Coarse densities over all lungfields.

Infarction Pneumonia

Infarction pneumonia. Follow up on chest films. Characteristic triangular densitiy based on the pleura. On consecutive films the top of the consolidation melts away like an icecube. An ordinary consolidation would loose its density diffusely.

Peripheral consolidation (Hampton hump) with pulmonary embolism in LLL. Characteristic triangular densitiy based on the pleura. On consecutive films the top of the consolidation melts away like an icecube. An ordinary consolidation would loose its density diffusely. There are different opinions as to the frequency of this remarkable phenomenon

Melting peripheral infiltration with pulmonary embolism in RLL. Chest film and CT scan, magnified view.

Peripheral consolidation in RLL with pulmonary embolism. Follow up of chest films.

Extensive Infiltrates

Diffuse confluent consolidations in middle lobe, lingula, and upper lobes of both sides. Supine bedside film fro ICU.

Pneumonia of the right lung with positive bronchograms.

Bilateral consolidations with bronchogram in right lower lungfield.

Extensive bilateral bronchopneumonia, partly consolidating. Follow up:
- on admission
- after 3 days
- after 9 days

Mycotic infections

Aspergilloma in the left upper lobe in a tuberculous cavity (saprophytic aspergilloma). There are several fungus balls (mycelomas), which change their position when the patient is turned from a supine to prone position.

Aspergilloma in right upper lungfield with characteristic myceloma at the bottom of the cavity

Aspergillum in the left upper lobe (infiltrative narcotizing aspergilloma). A cavity has developed with necrotic contents (no mycelloma!) with punctiform densities, probably calcifications.

Aspergilloma with mobile myceloma (CT in supine and prone position) in a cavity of an adenocarcinoma.

Infiltrates of aspergillus in both apical lung fields with changing appearance over 5 months. The 50-year old patient has a kidney failure with chronic kidney insufficiency. This was caused by a short intestine syndrome (fluids and electrolyte loss) in the course of Crohn´s disease.

Aspergilloma, well defined in the right lower lung field. It is a round infiltrate, possibly with necrosis, which however has no draining bronchus.

Aspergillosis (infiltrative and necrotizing). Follow-up over 12 weeks. After 7 weeks there is demarcation of necrosis, which forms the typical crescent sign. After healing a thin-walled cavity still exists 12 weeks later.

Aspergillosis, infiltrating and necrotizing, with typical crescent sign.

Aspergilloma with thin-walled cavity and mobile fungus ball.

Aspergilloma in the left upper lung field. The fungus ball in the small thin-walled cavity has a scalloping upper outline (reminding one of the buds and leaves of a water lily = water lily sign).

Aspergilloma. Chest film a.p. and lateral view. The left midfield shows a big cavity that is nearly completly filled with a myceloma - or necrotic material. This leaves but the typical crescent airspace.

Aspergillus cavity with fungus ball. Conventional tomography - in the age of multislice CT a historic document!

Aspergilloma on the right. Chest film a.p. and lateral view. The cavity is well shown in the lateral view.

Aspergilloma on the left. Chest film and CT in prone position. Cavity in left upper field with freely mooving myceloma.

Infiltrating aspegillosis, no formation of cavity. Chest film, magnified view, follow up.

Interstitial Pneumonia

Viral pneumonia. Interstitial pattern with fine lines radiating from the hila. There is a hazy transparency reduction.

Virus pneumonia with fine lines radiating from the hila.

Interstitial pneumonia (magnified view of left lower lung field) with consequent transformation (lower pictures) into an alveolar infiltrate. This shows spotted transparency reduction and bronchograms.

Pneumocystis carinii pneumonia. Supine film Partly fine linear (interstitial), partly spotty (alveolar) densities sometimes confluent densities with bronchograms. (Displaced endotracheal tube to the right main stem bronchus).

Pneumocystis carinii pneumonia. Supine film. (Pneumothorax on the left).

Disseminated flecks of calcification in the course of varizella pneumonia in childhood.

Disseminated small spots of calcification in the course of varizella pneumonia.

Other Infections

Ornithosis (synonym: psittacosis) with infiltrates in both sides of the mid fields of the lung. The protracted course of the disease often changes, showing " moving " densities.

Ornithosis. Healing process over 12 days.

Pneumocystis carinii pneumonia, CT in prone position. Geographically distributed ground glass densities. Dorsal existing additional fibrosis and small spotted infiltrates (arrows).

Pneumocystis carinii pneumonia. Chest films. In the course of the disease increasing butterfly-shaped densities starting from the hilum. The last film shows an alveolar pattern. This picture may have been preceded by a perihilar interstitial brush-like pattern in the early stage of the disease. Interstitial infiltrates, however, often rapidly change into an alveolar pattern.

Pneumocystis carinii pneumonia. Series of chest film and CT. Development of a pneumatocele (" premature emphysema "?) within 3 weeks.

Pneumatoceles (alleged " premature emphysema ") with a HIV+ patient.

Fig. 1, Fig. 2, Fig. 3;

Pneumocystis carinii pneumonia. The chest film shows transformation from a typical interstitial pattern to a spotted (alveolar) appearance within 14 days.

Pneumocystis carinii pneumonia. Typical interstitial infiltrate that develops butterfly-shaped from the hila. HIV+ patient.

Pneumocystis carinii pneumonia (not verified). Progress in an HIV+ patient.

Pneumocystis carinii pneumonia and miliary tuberculosis. The patient was HIV positive.

Follow up of pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia in an HIV+ patient.

Pneumocystis carinii pneumonia in an HIV+ patient. Observation over 8 weeks.

Legionella pneumonia in an HIV+ patient. The consecutive investigations demonstrate the variable appearance with lobar pneumonia , bronchopneumonia (4 wks) and abscesses.

Chlamydia pneumonia on the left. Slow onset without fever. CT shows ground glass appearance in left upper lobe. The greater fissure borders the consolidation.

Chlamydia pneumonia on the left. Follow-up examinations. The chest film shows homogeneous peripheral densities and an enlarged left hilum. There is a ground glass phenomenon in the CT scan. The greater fissure borders the consolidation. Chlamydiae are classified as bacteriae. They reproduce themselves intracellularly. The course of infection is milder in comparison to pneumonia caused by mycoplasms or viruses.

Chlamydia pneumonia on the left. Follow-up examinations. The chest film shows homogeneous peripheral densities and an enlarged left hilum.

Rickettsia (Q fever) in 9th segment on the left. Lobar manifestation. Coxiella burnetii is a gram positive Rickets that is transported to cattle by ticks. Man is infected by inhalation when handling live stock products. The extensive densities on x-ray exams are caused by hemorrhage, edema and mononuclear cellular infiltrates, usually in the lower lung fields. Symptoms are malaise, headache, high remittent fever, muscle and joint pain and dry cough. Frequently concomitant myocarditis, endocarditis, hepatitis or phlebitis is observed.

Mycoplasm pneumonia. CT scans. Clustered, small and sometimes confluent soft-contoured densities.

ORSA pneumonia (Oxacillin Resistant Staph. Aureus) of an ICU patient. 12 months follow-up. The single chest film gives no clue to the diagnosis.

ORSA pneumonia (Oxacillin Resistant Staph. Aureus), same patient. Exams done at the peak of disease and after recuperation.

Abscess

Abscesses in the anterior upper lobe segment on the right with fluid-air level formation. Chest film and CT. In CT there is a bronchogram in the consolidation beside the abscess cavity.

Abscess with fluid-air level in the anterior upper lobe segment on the right. Bronchogram in infiltrate.

Abscess below the right hilum with air-fluid level. Segmental atelectasis in the middle lobe with downward dislocation of the minor fissure.

Abscesses on both sides. Cavitation on the right. Difficult . The right-sided cavity forms a pointed angle at the upper pole to the thorax wall. This supports the diagnosis of an abscess.

Abscess development in the left upper lobe over 39 days starting from a small infiltrate.

Abscess in the right upper lobe. Healing takes place with contraction of the involved parenchyma.

Abscesses with cavitations in the anterior upper lobe segment on the right. Pa and lateral view after 2 and 3 weeks. While healing, the process shrinks. There are linear fibrotic remnants.

Cavitating abscess in the central lobe, 4th Segment. Chest film (A) and CT (B, C). CT shows the draining bronchus

Multiple intrapulmonal abscesses.

Lung abscess. Chest film and CT.

Abscess. The paravertebral mass was misinterpreted as a tumor. The contrast CT scan shows the strongly enhancing capsule of the segmented abscess. Consider also the pointed angle, which the abscess forms with the pleura: DD empyema! The abscess was operated on. The segments from the conventional chest film show the drained cavity with a basal contrast-air level (contrast was injected bronchoscopally to prove the bronchpleural fistula).

Consolidation with abscess on the left. CT scan.

Empyema / abscess. CT scans, magnified views. There is a fluid filled cavity in projection to the major fissure on the right. Nearby there is a consolidation with bronchograms (1st image). It is doubtfull if this is a fluid collection in the fissure (empyema) or in the lung parenchyma (abscess).

Infiltrates not by Infection

SIRS (Systemic Inflammatory Response Syndrome &endash; sepsis without infection). Chest film with consolidation in left lower lobe and after recuperation. The radiological pattern is unspecific.

Eosinophilic infiltrate in the left upper lobe, chest film.

"Moving " eosinophilic infiltrates. The left perihilar density remains stationary. The right-sided consolidation regresses. Consider in contrast to this the process in the left lower lung field!

Eosinophilic infiltrate in the left upper lobe. Chest film before and after therapy

Eosinophilic pneumonia in the upper fields of both sides. Chest film

Myeleran-induced fibrosis. Chest film.

Amiodaron (Cordarex®) induced fibrosis. The lingula has almost completely changed to a reticular pattern with bronchiectasis. Only small islands of lung parenchyma remain. There are broad peripheral pleural fibrosis and adjacent honeycombing in the 6th segment.

Acute allergic alveolitis of a bird breeder. There is yet no fibrosis. There are profuse alveolar densities (micronodules) in High Resolution CT.

Allergic alveolitis.

Allergic alveolitis. Part of CT image. Soft contoured centrilobular nodules, caused by fluid collection within the alveoli. Another part of a CT image.

Pigeon Breeder's Lung. CT shows end stage fibrosis, i.e. reticulation and honeycombing within almost the entire left lung.

Pigeon breeder's Lung with transition to fibrosis. After bronchoscopy with biopsy, a pneumothorax developed. Because of the rigidity of the lung it inflated only slowly. Due to thickening of the sublobular septae, the polygonal pattern of the lobules becomes apparent. There is honeycombing at the paravertebral base of the lung.

Usual Interstitial Pneumonia (UIP), CT. Typical is the heterogeneity of the pattern element as ground glass densities (black arrow, sign of acute alveolar processes), as well as fibrotic thickening of interlobular walls. The white arrows point to the core structures of secondary lobules, which become visible only through fibrosis. There are also reticulation (left side) and fibrous arcades on the pleural surface (black double arrow).

Desquamating interstitial pneumonia (DIP). CT. Homogeneous ground-glass density.

Desquamating interstitial pneumonia (DIP). The chest film shows a questionable faint haze. In CT there is homogeneous ground-glass density.

DIP. CT scan. Initially, DIP presents with homogenous ground glass density. Over the years, there have been fibrous changes.

DIP, same patient as above. CT scans of upper level. There are structural deformations of bronchovascular structures. They show indented, saw-like border. There are nodules as well as cystic destruction.

DIP. CT scans. Same patient as above.

Cryptogenic Organizing Pneumonia (COP), CT scans. Bilateral ground-glass densities. Bilateral consolidations.

COP. The chest film shows spotty densities on the right side.

Chronic lymphatic leukemia. CT scan. Bilateral leukemia consolidations.

Hodgkin Lymphoma with consolidation in lung parenchyma.

NHL (Non-Hodgkin-Lymphoma) with consolidations in both lungs. Chest film and CT scan. The infiltrations reach from the hila to the periphery.

Leukemia infiltration before and after treatment.

Pneumonitis after radiotherapy of a left-sided bronchial carcinoma. The geometric delineation of the area of ground-glass opacification represents the radiation field that was aimed towards the left mediastinum and hilum. The ground glass density may represent alveolitis (active inflammation), but may also be of fibrotic origin.

Pneumonitis. Pneumonectomy of left lung and radiotherapy for left central bronchial carcinoma. The sharply delineated border of the radiation ports may be seen both on the plain chest film and in CT.

Pneumonitis paramediastinal and bilateral. The clear-cut borders of the radiation fields can be clearly seen.

Pneumonitis. Chest film with an interval of 4 months, and CT. After radiation of the upper mediastinum, it shows a widening on the chest film. CT explains this as paramediastinal fibrosis of lung parenchyma.

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