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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 19 Chest X-ray appearances
442
Area of uniform lung opacification
Figure 19.1a
Right lower lobe pneumonia, silhouetting the right hemidiaphragm
(frontal image).
Figure 19.1b
Right lower lobe pneumonia, silhouetting the right hemidiaphragm
(lateral image).
AREA OF UNIFORM LUNG OPACIFICATION1
443
Figure 19.2
Right upper lobe atelectasis resulting from a large right hilar cancer
forming the classic “Golden’s S sign”.
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CHAPTER 19 Chest X-ray appearances
444
Figure 19.3
Apical fibrosis and bilateral hilar retraction due to stage 4
sarcoidosis.
Figure 19.4
Bilateral pleural effusions due to congestive heart failure (CHF).
Note that there is a pulmonary linear septal pattern with Kerley B lines.
AREA OF UNIFORM LUNG OPACIFICATION1
445
Figure 19.5
Pneumonectomy resulting in mediastinal shift to the right. Note
multiple BB pellets in the chest and median strenotomy wires.
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CHAPTER 19 Chest X-ray appearances
446
Round opacity (or opacities) >5 mm
in diameter
Beware of skin or rib lesions or artifacts from hair or clothing that can
mimic intrathoracic pathology.
Some differential diagnoses and typical outline evidence
Bronchogenic
carcinoma
(adenocarci-
noma, large cell:
commonly
peripheral; small
cell, squamous:
commonly
central)
Figures 19.2, 19.6
Suggested by: solitary opacity with irregular, lobulated,
or spiculated border ± hilar enlargement, destructive
bone changes in ribs, and other features of metastases.
Background cough, hemoptysis, cachexia. High prob-
ability of carcinoma if >3 cm (e.g., a mass)
Confirmed by: tissue diagnosis via bronchoscopy or
CT-guided biopsy
Pulmonary
metastasis
Suggested by: multiple rounded opacities ± background
history of neoplasia or lymphoma
Confirmed by: CT scan appearance ± biopsy
Rounded
pneumonia or
lung abscess
Suggested by: round opacity in child, cavitating thick-
rimmed lesion in adult. Background of raised inflamma-
tory markers, neutrophilia and cough, pyrexia, spiking
fevers (in abscess)
Confirmed by: sputum microscopy, culture, and
sensitivity resolution following appropriate antibiotic
therapy
TB granuloma
Figure 19.7
Suggested by: coin lesion ± cavitation in upper lobe.
Background history of TB exposure, lymphadenopathy
Confirmed by: CT scan appearance. AFB on smear or
culture
Rheumatoid
nodule
Suggested by: peripherally positioned, ± cavitatation
and frequently changed appearance over time.
Background history of rheumatoid arthritis with
multiple soft tissue nodules
Confirmed by: CT scan appearance and positive
rheumatoid serology
ROUND OPACITY (OR OPACITIES) >5 MM IN DIAMETER1
447
Histoplasmosis Suggested by: coin lesion ± cavitation in upper lobe.
Patient from appropriate geographical area (Midwest,
Ohio and Mississippi River Valleys, Africa) or
HIV
-positive
Confirmed by: CT scan appearance. Yeast-like organisms
in sputum. Positive complement fixation test
Wegener’s
granulomatosis
Figure 19.8
Suggested by: multiple rounded opacities ± cavitatation
with background of proteinuria, skin lesions, etc.
Confirmed by: serum anti-neutrophil cytoplasmic antigen
(ANCA) positivity, biopsy of lung lesion or kidney
Klebsiella
pneumonia
Suggested by: multi-lobar cavitating opacities in an
elderly patient
Confirmed by: growth on blood or respiratory cultures
and response to appropriate antibiotics
Hydatid cyst
Suggested by: Water lily sign, which is an opacity in a
lower lobe with dark cavity ± daughter cysts within
large cyst. History of contact with sheep, dogs, etc.
Confirmed by: CT scan appearance, positive complement
fixation test, or enzyme-linked immunosorbent assay
(ELISA)
Pulmonary AV
malformation
Suggested by: occasional hemoptysis
Confirmed by: CT thorax showing feeding blood vessel
on contrast-enhanced scan
Benign
tumors
Suggested by: lesion with no change over period of at
least a year and <1 cm with no symptoms
Confirmed by: fat in the lesion by CT (hamartoma),
excision and histopathology
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CHAPTER 19 Chest X-ray appearances
448
Figure 19.6
Left upper lobe primary bronchogenic carcinoma on frontal image of
the chest.
Figure 19.7
Small, calcified nodule in the left upper lobe laterally with a calcified
mediastinal lymph node, a result of granulomatous disease. This particular radiologic
appearance is known as a “Ghon” or “Ranke Complex.”
ROUND OPACITY (OR OPACITIES) >5 MM IN DIAMETER1
449
Figure 19.8
Wegener’s granulomatosis with large bilateral cavitary masses.
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CHAPTER 19 Chest X-ray appearances
450
Multiple nodules and miliary pattern
These are round lesions 2–5 mm in diameter of variable density, ranging
from small and soft in the miliary (<2 mm) pattern to larger and calcified
persistent pulmonary nodules seen after recovery from chickenpox.
Some differential diagnoses and typical outline evidence
Metastases
Figure 19.9
Suggested by: low-density nodules more profuse in the
lower lung zones ± mediastinal widening and other
manifestations of malignancy, e.g., lytic lesions in ribs.
History of malignancy, e.g., thyroid or renal cell
carcinoma. Anorexia and weight loss
Confirmed by: imaging, tissue diagnosis
Miliary
tuberculosis
Figure 19.10
Suggested by: innumerable grain-like, low-density
discrete nodules with history of TB contact
Confirmed by: AFB
on sputum, culture of bone
marrow or biopsy specimens from pleura, lung, liver,
or lymph nodes
Sarcoidosis
Figure 19.11
Suggested by: low-density nodules more profuse in
the perihilar and mid-lung zones. Bilateral hilar ±
paratracheal lymph node enlargement. History of
rash or uveitis
Confirmed by: histology showing noncaseating
granuloma with no acid-fast bacilli, iserum ACE
Persistent
pulmonary
nodules of
chicken pox
Suggested by: dense opacities suggesting calcification.
No current symptoms. History of adult-onset
chickenpox. Now rare in the United States
Confirmed by: no change over months on serial X-rays
Pulmonary
hemosiderosis
from mitral
stenosis with
pulmonary
hypertension
Figure 19.12
Suggested by: dense opacities due to calcification.
History of tapping left ventricular impulse (palpable
first heart sound)
Confirmed by: other clinical findings, ECG findings,
echocardiogram, and cardiac catheterization
Pneumoconiosis Suggested by: discrete opacities, mainly in upper lobes,
that eventually coalesce into mass-like regions (pro-
gressive massive fibrosis) with hilar retraction. History
of >10 years working in coal mining, metal mining, or
quarrying
Confirmed by: comparison with previous CXR.
HR-CT scan
MULTIPLE NODULES AND MILIARY PATTERN1
451
Figure 19.9
Multiple micronodular lung cancer metastasis with left PICC
(peripherally inserted central catheter) line
Figure 19.10
Miliary tuberculosis with multiple bilateral micronodules.
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