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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
452
Figure 19.11
Sarcoidosis with airspace disease showing the typical pattern of
midlung involvement; in this particular case there is no adenopathy (stage 3).
Figure 19.12
Pulmonary hemosiderosis at lung bases as a result of mitral valve
stenosis.
DIFFUSE POORLY DEFINED, HAZY OPACIFICATION1
453
Diffuse poorly defined, hazy
opacification
Some differential diagnoses and typical outline evidence
Pulmonary
edema
(cardiogenic, or
fluid overload,
or both)
Figure 19.13
(severe cases
may resemble
19.14)
Suggested by: symmetrical haziness more florid in a
perihilar distribution, fluffy alveolar opacities ± confluence,
(if fluid is in airspaces), Kerley B lines or peribronchial
cuffing (if in interstitium), or effusion (if in pleural space).
History of fluid overload ± heart disease, fine crackles in
lung bases
Confirmed by: ventricular dysfunction on echocar
diogram if cardiogenic and response to diuretics or
vasodilators
Acute
respiratory
distress
syndrome
(ARDS)
Figure 19.14
Suggested by: symmetrical diffuse, poorly defined opaci-
t
ies that become confluent. History of acute illness and
severe hypoxia. Normal heart size, no signs of left
ventricular failure (LVF). History of precipitating cause
(e.g., septic shock, trauma, transfusion, aspiration, drug
exposure, fat/amniotic fluid emboli, viral infection)
Confirmed by: acute onset, bilateral infiltrates, pulmo-
nary capillary wedge pressure (PCWP)
<19 mmHg or
no CHF
, PaO
2
/FiO
2
<200, in the presence of good LV
function
Infective
infiltration
due to viral
pneumonia,
PCP, bacterial
pneumonia
Figure 19.15
Suggested by: region of patchy pulmonary infiltrate ±
air bronchogram ± pleural effusion. If diffuse, more
likely to be viral or Pneumocystis pneumonia (PCP).
History of cough, sputum, raised inflammatory
markers, neutropenia (viral), or neutrophilia (bacterial)
Confirmed by: positive cultures or resolution following
appropriate antibiotics
Alveolar cell
carcinoma
Suggested by: region of poorly defined opacification
that may contain air bronchogram. History of progres-
sive breathlessness, copious watery, productive cough.
No resolution with antibiotic therapy
Confirmed by: sputum cytology, lung biopsy
Pulmonary
hemorrhage
Figure 19.16
Suggested by: region of poorly defined opacification
(can be diffuse) ± air bronchogram. History of cocaine
use, Goodpasture’s syndrome, SLE, Wegener’s
granulomatosis, or coagulopathy
Confirmed by: Bronchoscopy, CT appearance, renal
biopsy (for Goodpasture’s syndrome), evidence of SLE,
lung biopsy or serum ANCA positivity (for Wegener’s)
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CHAPTER 19 Chest X-ray appearances
454
Figure 19.13
Pulmonary edema and Kerley B lines in a patient on hemodialysis.
Figure 19.14
ARDS, showing patchy opacificaton in an intubated patient.
DIFFUSE POORLY DEFINED, HAZY OPACIFICATION1
455
Figure 19.15
Herpes simplex virus (HSV) pneumonia with diffuse infiltrates.
Figure 19.16
Diffuse pulmonary hemorrhage of uncertain etiology.
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CHAPTER 19 Chest X-ray appearances
456
Increased linear markings
This indicates thickening of the interstitial tissues.
Some differential diagnoses and typical outline evidence
Pulmonary
fibrosis
Figure 19.17
Suggested by: increased interstitial markings with
history of asbestosis exposure, pneumoconiosis due to
coal, silica, or beryllium, or medical history of collagen
vascular disease, sarcoidosis, or hypersensitivity
(extrinsic allergic alveolitis)
Confirmed by: increased reticular markings, traction
bronchiectasis, or honeycombing on HR-CT. Lung
biopsy
Interstitial
fluid =
pulmonary
edema
Figures 19.4,
19.13
Suggested by: smooth thickening of the interlobular
septa (Kerley B lines) with background lung crackles
Confirmed by: rapid resolution following diuretic
therapy or correct fluid balance or dialysis
Metastatic
cells =
lymphangitic
carcinomatosis
Suggested by: smooth thickening of the interlobular
septa with background of other features of malignancy
Confirmed by: HR-CT, lung biopsy, or progressive
malignant disease
Bronchiectasis
Figure 19.18
Suggested by: tram lines and rings with background of
cough with high volume of sputum (± foul and purulent
(if super-added infection)
Confirmed by: HR-CT
INCREASED LINEAR MARKINGS1
457
Figure 19.17
Idiopathic pulmonary fibrosis with a peripheral and basilar
predominance.
Figure 19.18
Extensive bronchiectasis with cylindrical and cystic features in this
34 year old male with cystic fibrosis (note that markings on film are reversed).
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CHAPTER 19 Chest X-ray appearances
458
Symmetrically dark lungs
Symmetrically dark lungs (no or
decreased lung markings)
Some differential diagnoses and typical outline evidence
Chronic
obstructive
pulmonary
disease (COPD)
Figure 19.19a,
19.19b
Suggested by: long, narrow heart and chest, flat
diaphragm, horizontal ribs with the seventh rib visible
anteriorly and eleventh rib visible posteriorly. Promi-
nent pulmonary arteries with peripheral pruning
(in pulmonary hypertension). Large, thin-rimmed dark
areas with no lung markings—bullae. Long history of
smoking
Confirmed by: Lung function tests showing fixed
obstructive deficit, FEV
1
<80%, FEV
1
/FVC <70%
Asthma Suggested by: hyperexpanded lungs. No loss of lung
markings. Background history of asthma
Confirmed by: spirometric improvement following
appropriate treatment
Figure 19.19a
COPD with pulmonary hypertension as evidenced by enlarged
central pulmonary arteries and peripheral arterial pruning (frontal image).
SYMMETRICALLY DARK LUNGS1
459
Figure 19.19b
COPD with pulmonary hypertension (lateral image) as evidenced
by enlarged pulmonary arteries and flattening of the diaphragms.
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CHAPTER 19 Chest X-ray appearances
460
Area of dark lung (no or decreased
lung markings)
Some differential diagnoses and typical outline evidence
Pneumothorax
Figure 19.20
Suggested by: visible lung edge with absence of lung
markings peripheral to this; mediastinal shift may occur
in severe cases. Beware of skin folds that may mimic a
lung edge. History of sudden onset of breathlessness
Confirmed by: more definitive appearance on expiratory
film or CT scan.
Tension
pneumothorax
(medical
emergency)
Suggested by: visible lung edge with absence of lung
markings peripheral to this, mediastinal shift away
from the collapsed lung. History of acute, progressive
dyspnea, tachycardia, low BP
Confirmed by: relief when a needle or catheter is
inserted, the lung re-expands, and vital signs normalize
Bulla
Figure 19.21
Suggested by: loss of lung markings inside lucent,
thin-rimmed circular region. History of COPD
Confirmed by: comparison with previous CXR, CT
thorax
Mastectomy Suggested by: no breast shadow
Confirmed by: history of mastectomy
AREA OF DARK LUNG (NO OR DECREASED LUNG MARKINGS)1
461
Figure 19.20
Right lateral pneumothorax with loss of lung markings and visible
lung edge.
Figure 19.21
Emphysema with large bilateral apical bullae and vascular distortion.
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