Fig. 4.31 Opacification of the right upper lung field representing a consolidation pattern in bacterial pneumonia in the RUL. Location is confirmed by horizontal fissure inferiorly on the PA and lateral, and the major fissure on the lateral

Pus (Exudate)

Pus from a variety of infections can cause pneumonia. Pneumonia generally respects lobes; hence distribution is lobar or multilobar. However, atypical pneumonia may be diffuse and bilateral.

Some pneumonias originate in the lung periphery where the Streptococcus pneumoniae reaches the lung via the airway. In lower right lobe pneumonia especially, aspiration should be considered since the right mainstem bronchus and bronchus intermedius are more vertical than on the left.

Bacterial Pneumonia

•Is most commonly caused by Streptococcus pneumoniae

•May present with mild to severe symptoms, including shaking chills, chattering teeth, severe chest pain, and a cough productive of rust-colored or greenish sputum

•May be febrile, diaphoretic, tachypneic, dyspneic, and/or cyanotic

Case 4.9

Figures 4.31 and 4.32 depict lobar consolidation in the RUL, with fissures limiting extension.

Findings

RUL: Large area of airspace opacification on the frontal view has both major and minor fissures as its inferior border. The lateral view demonstrates nicely the fissures of the right lung. Both RML and RLL remain well aerated.

Pattern: Consolidation.

Differential Diagnosis: Bacterial Lobar Pneumonia.

Fig. 4.32 Lobar consolidation pattern

on lateral. Note the airspace opacity limited inferiorly by the minor fissue anteriorly and the major fissure posteriorly

Case 4.10

In some cases, a consolidation can resemble a mass, as shown on the CXR in this case. Additionally, this case demonstrates radiopaque markers that attempt to show degree of inclination (however, unsuccessfully). Lastly, this AP portable is an example of a rotated right projection. (Note the clavicles are to the right of the spine.)

Findings: RUL opacity bordering minor fissure inferiorly, however, maintains fluffy superior margin.

Pattern: Consolidation.

Note: Mass could also be considered, however, since abutment to horizontal fissure inferiorly gives the impression of mass (such as malignancy). A follow-up CXR documenting the resolution is paramount to rule out mass in cases like this.

Differential Diagnosis: Pneumonia, loculated fluid in horizontal fissure (pseudomass); mass differential can be considered until ruled out by CT or follow-up CXRs.

Diagnosis: RUL bacterial lobar pneumonia, confirmed by resolution with antibiotics and follow-up CXR.

Note the small ball bearings (BBs) in the left marker indicating an upright projection. Experience with these, however, demonstrates that the BBs fall to this location starting at 30° of inclination. Work is being done to achieve higher accuracy (discussed in the pleural section of this book).