RADIOLOGY       JMFV  2017  

 
Chest 2: Infections o PA View X-Ray Image
Lecture by: Dr. FR Villanueva, MD § Good Bony Detail
Basic Radiology 2e by Chen et al § Mediastinum and Lung Posterior to Heart
Snorlax Notes, 2014 are not well demonstrated
General Categories of Lung Infiltrates (4i’s c + n)
This lecture would cover radiographic imaging techniques
employed in assessing the infected/inflammatory chest.

Infiltrate–general term for any abnormality/density in the lung

seen on radiographic images
Abnormal densities of the lung film:
• Infectious (interstitial pneumonia, tuberculosis)
• Inhalational (pneumoconiosis, asbestosis)
• Immunologic (SLE, Goodpasteur’s syndrome)
• Infarct (pulmonary emboli) REMEMBER: the closer an object is to the film,
• Cardiac (cardiogenic pulmonary edema) the sharper are the borders
• Neoplastic (tumors, nodules seen as masses) PA – can visualize the heart well since heart
*MEMORIZE 4IsCN! is close to the film
AP – can not visualize the heart well kasi
Imaging Modalities malayo sa film
The following may be used in the approach to diagnose any o Teleradiography –requisites of a good CXR
problem in the chest (trauma, infection, malignancy) § 6ft. (72in) distance between X-ray source
*At our stage, we should know the application of the & film
following modalities in the clinical set-up. § Postero-anterior Projection – heart will be
Chest X-Ray (CXR) closer to the film
Computed Tomography (CT) § Upright Position – to preserve the tonicity
Ultrasound (US) of the heart
Nuclear Imaging: Positron Emission Tomography (PET) § End inspiratory effort (suspended
PET-CT or PET-MRI respiration) – to increase lung volume
Magnetic Resonance Imaging (MRI)
o 2 basic structures on the film
Chest X-Ray § Mediastinum – Heart + Great Vessels
• 2D image of a 3D object § Lung Parenchyma
o 2 types Lung Parenchyma
§ Plain Film – traditional x-ray image o Normal: you should
printed on a film only see the
§ Digital X-ray – newer version where the pulmonary
images are digital hence can be vasculature on the
accessed using a computer/smartphone, lower fields +
higher resolution superimposed ribs
o Most commonly requested screening procedure (LEARN TO IGNORE
for various disease entities BONES)
o Chest x-rays are usually analog o Blood vessels are not
normally prominent in
• Posterior Anterior (PA) view the upper fields
§ Due to gravity à blood pools on the
lower fields
o Cephalization – prominent pulmonary vasculature
on the upper lung fields which may suggest
pulmonary congestion/CHF
o CXR – good evaluation of early pulmonary
congestion

Mediastinum: Heart, and Hila

o Patient erect with the X-ray source at the back of o Seen at the midline
the patient & the film directly in front
o Taken at the end of maximum inspiration – to
increase lung volume for better visualization

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• Lateral View PET Scan
o Left side against the film plate then arms • Nuclear Imaging: Positron Emission Tomography
overhead, X-ray beam travels from right to left (PET)
through the patient: hence AKA left lateral view • Application: Imaging of pulmonary vessels particularly in
o Good supplement to PA view the diagnosis of pulmonary embolism (e.g., technetium-
§ Find abnormalities hidden on the frontal 99)
film • More or less physiologic (functional)
§ Confirm abnormalities suspected from o Depicts spatial distribution of metabolic or
frontal film biochemical activity in the body
§ Blind area on PA = posterior portion of o Useful in detecting/evaluation of possible
the heart malignancies
o “Our best friend” Don’t be afraid to look at it!
PET-CT or PET-MRI
• Combines Positron Emission Tomography with CT or
MRI to produce a single superimposed image of higher
quality
• Application: Both Anatomic and Functional visualization –
useful in locating the exact anatomical site of a
malignancy

MRI
• Magnetic Resonance Imaging (MRI)
• Not useful in visualizing lung parenchyma – difficult to
apply in the aerated lung due to H ions in air interferes
• Before the advent of CT, CXR was the gold standard for with signal
chest imaging • Application: Visualization of mediastinum and chest wall
o A NORMAL CHEST X-RAY FILM DOES NOT problems specially tumors
EXCLUDE SIGNIFICANT DISEASE
o CT may exclude significant disease
• Current GOLD STANDARD for evaluating lung Diseases/Abnormalities seen on Imaging Modalities
parenchymal diseases = High Resolution CT (HRCT) • Air Bronchogram
• Parenchymal Lung Diseases (Alveolar + Interstitial)
• Bacterial Pneumonias
Computed Tomography (CT) • Aspergilloma
• Also makes use of X-rays • Reactivation Tuberculosis
§ X-ray à Patient à Transmitted x-ray à • Miliary Tuberculosis
detector à computer à CT Image • Silicosis
§ Same major structures seen on plain • Wegener’s Granulomatosis
film/digital X-ray but CT creates a more • Thromboembolic Disease
enhanced image with more detail • Pulmonary Edema
• Multiplanar view – the chest may be evaluated in the • Lung Mass
coronal, sagittal or axial view (axial-most common) • Pancoast Tumor
• Image Resolution: Multi-slice CT > Single slice CT • Goodpasteur’s Syndrome
• Gold standard for chest imaging (particularly lung • Systemic Lupus Erythematosus
parenchymal imaging)
• Current GOLD STANDARD for evaluating lung Air Bronchogram
parenchymal diseases = High Resolution CT (HRCT) • Air in the bronchus becomes visible on X-Ray film, which
o Can identify very small pathologies is NOT normal
• Normally, bronchi can not be seen on X-Ray because
o Their walls are thin
Ultrasound (US) o They contain air
• Best application: evaluating fluid collections o They are surrounded by air
o Fluid quantification usually underestimates actual • When something of fluid density fills the alveoli, air in
volume bronchus becomes visible, like
• Assessing abnormalities found in Physical examination to o Pulmonary edema fluid
determine the nature or source (fluid, atelectasis or o Blood
consolidation) o Gastric aspirate
• Fluid quantification usually underestimates actual volume o Inflammatory exudate
• The visibility of air in the bronchi because of surrounding
airspace disease is called an “air bronchogram”

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• An air bronchogram
is almost always a
sign of airspace
disease
Aspiration
The black branching Pneumonia
structures are the result at both lung bases
of air in the bronchi, now
visible because a density
other than air surrounds
them (in this case it is
inflammatory exudate
from a pneumonia) Interstitial Lung Disease
• No air bronchograms
• Discrete & inhomogeneous
Parenchymal Lung Disease • Made up of lines (reticular) or dots (nodular) or both
• 2 Types (reticulonodular)
o Alveolar (Airspace) Disease • Common interstitial Lung diseases
o Interstitial Lung Disease o Cancer–1° or 2° - most common
o Sarcoidosis
o Cystic fibrosis
o Asbestosis

Cystic Fibrosis - A
differential for
pneumonia, while it also
is inhomogenous, there
is no branching patten

Alveolar (Airspace) Disease

• Has air bronchograms Bacterial Pneumonias
• Fluffy and indistinct
• Confluent and homogeneous *We usually do not state the diagnosis of an infection as the
• May have segmental or lobar distribution exact microorganism because what radiologists see are the
gross images of the lung and not microscopic slides for
microbiologic testing. But we know the most typical
presentation of different organisms on various imaging
modalities.

*We give impressions to the clinicians on what organism may

probably be causing the infection; this may help the clinician
on the initial antibiotic choice

• Gram positive pneumonia

o Pneumococcal – lobar consolidation
o Staphylococcal – produces pneumatocoele
o Streptococcal – abscess formation
This disease is fluffy and indistinct in its margins. It is o Nocardiosis
confluent and tends to be homogeneous. In both upper lobes, • Gram negative pneumonia – typical abscess formation
you can see air bronchograms. This is an alveolar (airspace) o Pseudomonas
disease, in this case pulmonary edema on a non- cardiogenic o Klebsiella
basis. o Enterobacter
• Common Alveolar Lung Diseases o Serratia
o Pneumonia & Pulmonary edema – most common o Anaerobic
o Pulmonary hemorrhage
o Aspiration pneumonia – aspirate is gravity-
dependent
o Bronchogenic carcinoma

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Pneumococcal Pneumonia
• Most common gram positive pneumonia
90% community acquired
• Organism: strep pneumoniae
• Inflammatory edema in alveoli spread via pores of Kohn
to more lateral alveoli

X-Ray Findings
• Organism aspirated into lungs
• Predilection for lower lobes Day 1 to Day 4 – we can see rapid development of
• Extensive infiltrate abutting pleural surface pleural effusion and multi-lobar consolidation on the
• Prominent air bronchograms right lung
o DDX: Staph has no air bronchogram
• Does not respect segmental boundaries

A   B  

Later on, it will produce the typical Air-fluid Level like a

half-full glass of water, sa taas air tapos sa baba yung
tubig. This will shift depending on gravity

C   D  

A & C. Lobar consolidation on the Right upper lobe - result

of replacement of air in the alveoli by transudate, pus or blood
cells: yung white area sa right upper lobe, fluid yun. There is
also atelectasis of the RUL - collapse of a part of the lung
due to a decrease in the amount of air in the alveoli (kasi
nareplace ng fluid) resulting in lung volume loss and
increased density, air bronchograms could also be seen on 2 weeks later during the late coarse of the disease we
X-ray (A&C) & CT (B&D as branching) can see the development of a pneumatocoele – thin
walled cavitations, this is the stage in which the
pneumatocoele may rupture and produce pneumothorax
Staphylococcal Pneumonia
• Gram Positive Pneumonia by S. aureus
• Most common bronchopneumonia Klebsiella Pneumonia
• Overwhelming majority hospital-acquired • Gram Negative Pneumonia
• Rarely develops in healthy adults X-Ray Findings
• Most common cause of death during influenza epidemics • Bulging fissure sign
o As this infection produces excessive amounts of
X-Ray Findings inflammatory exudate, the affected lung expands
• Rapid spread through lungs and the fissures will be pushed and will bulge (in
• Empyema, especially in children the image below, the minor fissure accumulates
• No air bronchogram (due to rapid onset of disease pus and is pushed downwards)
& pleural effusion, it may not be present)
• Pneumothorax, pyopneumothorax
• Abscess formation, pneumatocoele The minor fissure should be
• Bronchopleural fistula higher at the level of the
th
4 anterior rib/ hilum, not at the
In children level of the lower hemithorax (arrow)
• Rapidly developing lobar/multilobar consolidation
• Rapidly developing Pleural effusion (90%)
• Pneumatocoele development during the late course of
the disease

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• Abscess and cavity formation - thick walled air fluid levels Reactivation TB
representing abscess formation (below) • M tuberculosis is aerobic, so you see them occupying
areas of the lung which has high O2 tension
o Apical segments of upper lobes
o Superior segments of lower lobes
• Atypical areas for TB
o Lower lobes of the lung – seen in
immunocompromised patients
• Can be either alveolar or interstitial lung disease (or both)
• Most cases in adults occur as reactivation of 1° focus of
infection acquired in childhood
• Pleural effusion and empyema • Caseous necrosis and tubercle are pathologic hallmarks
of post 1° TB
• Tubercle = accumulations of mononuclear macrophages,
Pseudomonas Pneumonia Langhan’s giant cells surrounded by
• Gram negative pneumonia with multiple cystic lucencies lymphocytes/fibroblasts
& lung abscess • Chronic TB can cause fibrosis • Usually found in areas of
the lungs with high O2 tension (superior apical, superior
segments of L lobe)

Aspergilloma
• Ball in cavity (usually movable)
• Migrates to the dependent position (prone/supine)
• Crescent sign - semilunar air space above mass density

Bronchogenic spread – tend to spread to the bronchi (can be

mistaken for pneumonia, but knowing the clinical background,
it’s quite easy to differentiate)

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Miliary TB • 4 clinical criteria for the diagnosis
• Hematogenous dissemination of TB bacilli: common in 1° o Nasal or oral inflammation (bloody discharge or
Tuberculosis ulcers)
o May involve extrapulmonary organs o Abnormal chest radiograph showing nodules,
• Clinically evident military TB rarely occurs fixed infiltrates, or cavities
• May not manifest itself for many years after infection o Abnormal urinary sediment (microscopic
• Fine granular pattern/nodules evenly distributed on both hematuria or red cell casts)
lung fields o Granulomatous inflammation on biopsy of an
artery or perivascular area.
• Gold standard for diagnosis – pathologic finding of
necrotizing granulomatous vasculitis, particularly by open
lung biopsy.

X-Ray Findings
• Pulmonary Hemorrhage
• Lung Masses – single or multiple pulmonary nodules (3-
10mm in diameter) + focal opacities involving localized
areas of consolidation
• Cavitation and Refilling –
• Thick Walled Cavity - uni/multilocular lesions with
typically irregular outer wall margins representing air-fluid
levels (indicate secondary infection with S aureus)

Silicosis
X-Ray Findings
• Multiple small rounded opacities
• Usually in upper lobes
• May have ground glass appearance
• May occasionally calcify centrally (20%)
• Lymph node enlargement common
• Eggshell calcification of hilar nodes (5%)
o DDx: Sarcoidosis
• Large opacities are conglomerations of small
opacities

Wegener’s Granulomatosis
• Systemic vasculitis of medium and small arteries,
venules, arterioles, and occasionally larger arteries
o Etiology: Unknown
o Proposed etiology: Ag-Ab immune reaction
• Wegener's triad: upper respiratory tract, lower respiratory
tract, and kidney involvement Thromboembolic Disease
o Limited form of Wegener's = upper and lower • Westermark’s Sign
respiratory tracts ONLY • Dilation of pulmonary arteries proximal to emboli o
• Symptoms: persistent rhinorrhea, epistaxis, oral/nasal Collapse of distal vasculature
ulcers, sinusitis, arthalgias, fever, and cough • Appearance of a sharp cut-off
• Wegener's + alveolar hemorrhage: dyspnea, hemoptysis, • Abrupt cutoff and increased caliber of descending branch
hypoxemia, and anemia of PA: “Knuckle Sign”

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• Classic triad
o Hampton's hump
o Normal Radiograph
o Sub-segmental atelectasis

Pulmonary Edema
• Occurs when the alveolar beds get engorged in the lungs
• Cephalization of pulmonary vasculature
• Kerley lines – linear opacity, usually 1 to 2 mm in width,
produced by thickening of the interlobular septa and often
due to either edema or cellular infiltration.
• Haziness of pulmonary vascular shadows
• Diffuse alveolar edema
o Medullary distribution
o Butterfly or bat wing appearance o Soft fluffy
coalescing Lung Mass
o Air bronchogram • Round or oval
o Rapid onset and clearance • Sharp margin
• Homogenous
• No respect for anatomy
• Lung Cancer: Large cell

Pleural Effusion
• Fluid development between the parietal & visceral pleura;
fluid may be exudative or transudative
o Transudate – low protein content; CHF
o Exudate – high protein content; infection
• Bilateral
• Subpulmonic
• Right larger
• "Vanishing tumors" - Fluid in fissures
• Normal versus enlarged heart
• Upper lobe distribution
o Neurogenic pulmonary edema

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Pneumothorax Goodpasteur’s Syndrome
• Air inside the thoracic • Disease of young adults (Most are men)
cavity but outside the lung • Autoimmune disease involving Anti-BM antibodies
ie air in the pleural space attacking the basement membrane of
• You should be able to o Lungs – Pulmonary hemorrhage
identify the visceral pleura o Kidneys - Glomerulonephritis
(normally adherent to the • DDx: Pulmonary Hemorrhage (non-autoimmune)
lung) then outside it would o Also characterized by repeated episodes of
be an area with no lung pulmonary hemorrhage
density kasi air na yun o Also produce iron-deficiency anemia
mejo nagcollapse yung o Also can produce pulmonary insufficiency
lung

Systemic Lupus Erythematosus

• Pleural effusion
• Discoid atelectasis
• Patchy infiltrates at the bases
• DDx: thromboembolic disease
• Lungs and pleura involved more often in lupus than other
collagen vascular diseases
• Type III immune complex phenomenon

Glossary of Terms from the Book

This image shows a close-up of a pneumothorax in an upright • Acinar Pattern (synonyms: alveolar pattern, airspace
PA film as a white pleural line (red arrow) with atmospheric disease, consolidation): A collection of round or elliptic, ill-
air outside of it. No pulmonary vascular markings are seen defined, discrete or partly confluent opacities in the lung,
outside of the line. each measuring 4 to 8 mm in diameter and together
producing an extended, inhomogenous shadow.
• Air bronchogram: A branching lucency that represents
Pancoast Tumor the roentgenographic shadow of an air-containing
• Bone Destruction is common bronchus peripheral to the hilum and surrounded by
• 1st rib most commonly affected airless lung (whether by virtue of absorption of air,
• Squamous cell most common type replacement of air, or both), a finding generally regarded
• Involvement of the sympathetic chain and stellate as evidence of the patency of the more proximal airway.
ganglion • Air-fluid level: A local collection of gas and liquid that,
when transversed by a horizontal x-ray beam, creates a
shadow characterized by a sharp horizontal interface
between a gas density above and liquid density below.
• Air space: The gas containing portion of lung
parenchyma, including the acini and excluding the
interstitium and purely conductive portions of the lung.
• Anterior junction line: A vertically oriented linear opacity
approximately 1 to 2 mm wide, produced by the shadows
of the right and left pleural spaces in intimate contact
between the aerated lungs anterior to the great vessels. It
is usually obliquely oriented, projected over the tracheal
air column, below the level of the clavicles.
Peripheral Lung Nodule • Aortopulmonary window: A zone of relative lucency
• Causes of Lung Nodules (in order) seen on both PA and lateral chest radiographs bounded
o Granulomas medially by the left side of the trachea, superiorly by the
o Bronchogenic carcinoma inferior surface of the aortic arch, and inferiorly by the left
o Hamartomas pulmonary artery The pleural surface of the
o Metastases aortopulmonary (AP) window is normally concave;
convexity of the AP window suggests lymphadenopathy.
• Atelectasis: Less than normal inflation of all or a portion
of lung with corresponding diminution in volume.
Qualifiers are often used to indicate extent and
distribution (linear or platelike, subsegmental, segmental,

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or lobar), as well as mechanism (resorption, relaxation, • Lymphadenopathy (synonym: adenopathy):
compressive, passive, cicatricial, adhesive). Enlargement or abnormality of lymph nodes.
• Azygoesophageal recess: On the frontal chest • Mass: Any pulmonary or pleural lesion greater than 3 cm
radiograph, a vertically oriented interface between air in in diameter.
the right lower lobe, and the adjacent mediastinum • Miliary pattern: A collection of tiny (1 to 2 mm in
containing the azygos vein and the esophagus. It projects diameter) discrete opacities in the lungs, generally
in the middle of the heart and spine on the frontal view. uniform in size and widespread in distribution.
• Bleb: A thin-walled lucency within or contiguous to the • Nodular pattern: A collection of innumerable small,
visceral pleura. discrete opacities (2 to 10 mm in diameter), generally
• Bulla: A sharply demarcated area of avascularity widespread in distribution.
(lucency) within the lung measuring 1 cm or more in • Nodule: A sharply defined, discrete, circular opacity up to
diameter and possessing a wall less than 1 mm in 3 cm in diameter within the lung.
thickness. • Opacity: The shadow of tissue that attenuates the x-ray
• Carina: The bifurcation of the trachea into right and left beam more than surrounding tissue. On a radiograph,
main bronchi. areas that are more white than the surrounding area are
• Cavity: A gas-containing space within the lung said to be more opaque.
surrounded by a wall whose thickness is greater than 1 • Posterior junction line: A vertically oriented, linear
mm and often irregular in contour. opacity approximately 2 mm wide, produced by the
• Fissure: The infolding of visceral pleura that separates shadows of the right and left pleurae in intimate contact
one lobe, or a portion of a lobe, from another. between the aerated lungs, representing the plane of
Radiographically visible as a linear opacity normally 1 contact between the lungs posterior to the trachea and
mm or less in width. Qualifiers: minor (horizontal), major, esophagus, and anterior to the spine; the line may project
accessory, azygos, anomalous. above and below the suprasternal notch.
• Ground-glass pattern: A finely granular pattern of • Posterior tracheal stripe: A vertically oriented linear
pulmonary opacity such that pulmonary vessels remain opacity 2 to 5 mm wide, extending from the thoracic inlet
visible. The degree of opacity is not sufficient to result in to the bifurcation of the trachea, visible on the lateral
air bronchograms. radiograph, representing the posterior tracheal wall and
• Hilum (plural: hila): Anatomically, the depression or pit in contiguous mediastinal tissue (anterior, and often
that part of an organ where the vessels and nerves enter. posterior, walls of the esophagus).
On chest radiographs, the term hilum represents the • Primary complex: The combination of a focus of
composite shadow of the bronchi, pulmonary arteries and pneumonia due to a primary infection (e.g., tuberculosis
veins, and lymph nodes on the medial aspect of each or histoplasmosis), with granulomas in the draining hilar
lung. or mediastinal lymph nodes. (Synonym: Ranke complex.
• Honeycomb pattern: A number of ring shadows or cystic The term Ghon focus describes the pulmonary lesion that
spaces within the lung representing airspaces 5 to 10 mm has calcified. Ranke complex is the term to describe the
in diameter with walls 2 to 3 mm thick that resemble a combi- nation of the Ghon focus and calcified hilar lymph
true honeycomb. The finding implies interstitial fibrosis nodes.)
and “end-stage” lung disease. • Reticular pattern: A collection of innumerable small,
• Interface (synonyms: edge, border): The boundary linear opacities that together produce the appearance of
between the shadows of structures of different opacity a net.
(eg, the lung and the heart). • Reticulonodular pattern: A collection of innumerable
• Interstitium: A continuum of loose connective tissue small, linear and nodular opacities that together produce
throughout the lung consisting of three subdivisions: (a) the appearance
bronchoarterial (axial), surrounding the bronchoar- terial • of a net and superimposed small nodules.
bundles; (b) parenchymal (acinar), between the alveolar • Right tracheal stripe: A vertically oriented linear opacity
and capillary basement membranes; and (c) sub- pleural, 2 to 3 mm wide, extending from the thoracic inlet to the
between the pleura and lung parenchyma and continuous right tracheobronchial angle. It represents the right
with the interlobular septa and perivenous interstitial tracheal wall and contiguous mediastinal tissue (visceral
space. and parietal pleurae of the right lung).
• Line: A longitudinal opacity no greater than 2 mm in • Septal line (synonym: Kerley line): A linear opacity,
width. usually 1 to 2 mm in width, produced by thickening of the
• Lobe: One of the principal divisions of the lungs (usually interlobular septa and often due to either edema or
three on the right, two on the left) enveloped by the cellular infiltration.
visceral pleura except at the hilum. The lobes are • Silhouette sign: The effacement of an anatomic soft-
separated in whole or in part by pleural fissures. tissue border by either a normal anatomic structure or a
• Lucency (synonym: radiolucency): The shadow of pathologic state, such as airlessness of adjacent lung or
tissue that attenuates the x-ray beam less effectively than accumulation of fluid in the contiguous pleural space.
surrounding tissue. On a radiograph, the area that • Stripe: A longitudinal opacity 2 to 5 mm in width.
appears more nearly black, usually applied to areas of air • Tramline shadow: Parallel or slightly convergent linear
density or fat density. opacities that suggest the projection of tubular structures,
generally representing thickened bronchial walls.

UST Faculty of Medicine & Surgery  |  Chest  Infections   9