ABNORMAL CHEST
RADIOGRAPHS: A
PRESENTATION ON
CONSOLIDATION,, PLEURAL
EFFUSION, ABSCESS,
PNEUMOTHORAX, AND
LUNG CAVITIES
Opara Ugochukwu.
OUTLINE
1. INTRODUCTION
2. CONSOLIDATION
3. LUNG ABSCESS
4. PLEURAL EFFUSION
5. PNEUMOTHORAX
6. LUNG CAVITY
7. CLINICAL VIGNETTES
8. REFERENCES
INTRODUCTION
• The chest radiograph/CXR is anecdotally thought to be the most
frequently performed radiological investigation globally (Gefter et al.,
2023).
• Projections: PA, AP, lateral, lateral decubitus etc
• Indications: respiratory dx, cardiac dx, trauma, mets, post-op imaging,
medical fitness etc
CONSOLIDATION
• Consolidation refers to the replacement of normal air-filled lung
parenchyma with a substance such as fluid, pus, or cellular infiltrate
• Causing increased density in affected lung regions, obscuring normal
air-filled spaces.
• Increased opacification!
• Causes: pneumonia(commonest), pulm edema, hemorrhage, mets
etc
Radiographic Features
A. Opacification:
1. Consolidation appears as an area of increased opacity on the X-ray. (The
consolidated region “appears whiter" than the surrounding air-filled alveoli and
bronchi.)
2. The affected lung area appears denser than the surrounding healthy lung tissue.
3. Opacity can vary from subtle haziness to complete white-out of the affected area
B. Air Bronchograms:
1. Dark lines representing air-filled bronchi within the opacified area.
2. Indicates that the bronchi within the consolidated region remain patent and filled
with air.
Radiographic Features
C. Lobar Distribution:
1. Consolidation may affect an entire lobe (lobar consolidation) or be more
focal.
2. Lobar consolidation may indicate bacterial pneumonia affecting a specific
lobe.
3. Helpful in narrowing down the differential diagnosis.
D. Ill-defined Borders:
1. The borders of the consolidated area may be hazy or poorly defined.
2. Reflects a more diffuse or widespread involvement.
PLEURAL EFFUSION
• Accumulation of fluid in the pleural space, the potential space between the
visceral and parietal pleurae.
• The parietal pleura lines the inside of the thoracic cage, and the visceral
pleura adheres to the surface of the lung parenchyma, including its
interface with the mediastinum and diaphragm
• Normally, several hundred milliliters of pleural fluid are produced and
reabsorbed each day. Fluid is produced primarily at the parietal pleura from
the pulmonary capillary bed and is resorbed both at the visceral pleura and
by lymphatic drainage through the parietal pleura.
Causes of pleural effusion
Excess formation of fluid
• Congestive heart failure
• Hypoproteinemia
• Parapneumonic effusions
• Hypersensitivity reactions
Decreased resorption of fluid
• Lymphangitic blockade due to tumor
• Elevated central venous pressure
• Decreased intrapleural pressure
Radiographic features
a. Blunting of Costophrenic Angles:
Normal costophrenic angles appear sharp and clear. In pleural effusion,
these angles are blunted or obscured.
b. Meniscus Sign:
The fluid layer assumes a concave shape along the lateral chest wall,
forming a meniscus. The fluid level has a curved appearance, indicating
the boundary between the pleural fluid and the compressed lung.
Radiographic features
c. Mediastinal Shift:
Large pleural effusions can cause a shift of the mediastinum away from
the affected side.
d. Opacity Above the Diaphragm:
Appearance: Fluid may accumulate in the costophrenic sulcus,
extending above the diaphragm.
PNEUMOTHORAX
• Presence of air in the pleural space, leading to partial or complete
collapse of the lung
• A collection of air within the pleural space between the lung (visceral
pleura) and the chest wall (parietal pleura).
• Spontaneous pneumothorax (primary vs secondary).
• Traumatic pneumothorax.
• Tension pneumothorax
Radiographic features
a. Visualization of Visceral and Parietal Pleura Lines:
In a normal chest X-ray, the visceral and parietal pleurae are in
apposition and not visible. In pneumothorax, air in the pleural space
separates these two layers, making the pleural lines visible. This is
known as the "pleural line" sign.
b. Lung Margin and "Deep Sulcus" Sign:
Typically, the lung margin extends to the chest wall. The lung margin
may appear more sharply defined, and a deep costophrenic sulcus may
be seen on the affected side in pneumothorax.
Radiographic features
c. Collapse of Lung Tissue:
Pneumothorax leads to a decrease in the volume of the affected lung.
The lung may appear darker due to decreased air content.
d. Shift of Mediastinum:
The mediastinum may shift away from the side of the pneumothorax. A
tension pneumothorax can cause a significant shift and compression of
mediastinal structures
Radiographic features
e. Absent Lung Markings:
Lung markings are typically seen on chest X-rays, representing the branching pattern of
airways and blood vessels. In pneumothorax, there is an absence of lung markings in the
affected area due to lung collapse.
f. Horizontalization of Ribs:
Ribs have a downward slope as they approach the diaphragm. Pneumothorax: Ribs may
appear more horizontal as they lose contact with the lung.
g. Shifting of Trachea:
Normal Position: The trachea is centered within the mediastinum.
Pneumothorax: Tracheal deviation away from the affected side may be seen in severe
cases.
Deep sulcus sign. In the supine position, air in a relatively large
pneumothorax may collect anteriorly and inferiorly in the thorax and
Visceral pleural line in a pneumothorax. You must see the manifest itself by displacing the costophrenic sulcus inferiorly, while
visceral pleural line to make the definitive diagnosis of a at the same time producing increased lucency of that sulcus. This is
pneumothorax called the deep sulcus sign and is a sign of a pneumothorax on a supine
radiograph. Notice how much lower the left costophrenic sulcus
appears than the right sulcus (white arrow).
LUNG CAVITY
• aka pulmonary cavity
• thick-walled abnormal gas-filled spaces within the lung.
• They are usually associated with a nodule, mass, or area of
consolidation.
• They are defined as "a gas-filled space, seen as a lucency or low-
attenuation area, within pulmonary consolidation, a mass, or a
nodule"
LUNG CAVITY
Pathology: The cause of pulmonary cavities is broad. They may
develop as a chronic complication of a pulmonary cyst or
secondary to cystic degeneration of a pulmonary mass. They
may enlarge or involute over time.
Aetiology: malignancy(bronchogenic,
squamous),infection(tuberculosis, septic pulm emboli),
inflammation, GPA, congenital(bronchogenic cyst)
Radiographic Features
a. Cavity Wall Thickness:
Thin-Walled Cavities: Cavities with thin walls may suggest benign etiologies, such as
infectious granulomas.
Thick-Walled Cavities: Thicker walls may be seen in more chronic or necrotic
processes, including malignancies.
b. Cavity Shape:
Irregular Cavities: Malignancies or chronic infections may lead to irregularly shaped
cavities.
Round or Oval Cavities: More characteristic of infectious or inflammatory etiologies,
including abscesses.
Radiographic Features
c. Air-Fluid Levels:
Fluid Levels: Cavities containing fluid may show air-fluid levels on imaging,
suggesting the presence of infection or abscess.
d. Surrounding Infiltrates or Opacities:
Infectious Etiologies: Cavities associated with surrounding infiltrates may suggest
infectious causes, such as tuberculosis or bacterial pneumonia.
Fungus Balls: Fungal infections like aspergillosis can form balls within cavities.
LUNG ABSCESS
• Lung abscess is defined as a circumscribed area of pus or necrotic debris in lung
parenchyma, which leads to a cavity, and after formation of bronchopulmonary
fistula, an air-fluid level inside the cavity.
• A lung abscess is a localized collection of pus within a cavity formed by the
necrosis of lung tissue
• Contributing factors for lung abscess are: elderly, dental/peridental infections
(gingivitis-with bacterial concentration >1011/mL), alcoholism, drug abuse,
diabetes mellitus, coma, artificial ventilation, convulsions, neuromuscular
disorders with bulbar dysfunctions, malnutrition, immunosuppressants, mental
retardation, GERD, bronchial obstruction, inability to cough, sepsis
• Dy/dx: cavitary pneumoconiosis, excavating bronchial ca, tuberculosis, infected
emphysematous bullae etc
Radiographic Features
1. Cavity Appearance:
Cavitation: Lung abscesses typically present as well-defined cavities within the lung
parenchyma.
Wall Thickness: The cavity walls may vary in thickness, with thinner walls
suggesting acute abscesses and thicker walls indicating a more chronic process.
2. Location:
Common Sites: Lung abscesses often occur in the dependent regions of the lung,
such as the posterior segments of the upper lobes or the superior segments of the
lower lobes.
Apical vs. Basal: Depending on the cause, abscesses may be seen more frequently
in the upper or lower lung zones.
Radiographic Features
3. Air-Fluid Levels:
Presence: Fluid accumulation within the cavity may lead to the formation of air-
fluid levels, particularly when the patient is in an upright position.
Diagnostic Sign: The presence of air-fluid levels is a characteristic radiographic sign
associated with lung abscesses.
4. Contralateral Shift:
Mediastinal Shift: Large abscesses may cause a shift of the mediastinum toward the
contralateral side.
REFERENCES
• Tobi Olajide. Decoding abnormal chest radiographs: a presentation on
consolidation, abscess, pleural effusion, pneumothorax, and lung cavities
• Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C,
Tsakiridis, K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D.
Lung abscess-etiology, diagnostic and treatment options. Ann Transl Med. 2015
Aug;3(13):183. doi: 10.3978/[Link].2305-5839.2015.07.08. PMID: 26366400;
PMCID: PMC4543327.
• Karkhanis VS, Joshi JM. Pleural effusion: diagnosis, treatment, and management.
Open Access Emerg Med. 2012 Jun 22;4:31-52. doi: 10.2147/OAEM.S29942.
PMID: 27147861; PMCID: PMC4753987.
