Case 20 - Test Your Skill in Reading Pediatric Chest Radiographs

Volume 3, Case 20
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaiʻi John A. Burns School of Medicine

Test your skill in reading these 16 pediatric chest radiographs. Many of these have subtle findings. Unfortunately, subtle findings become even less obvious when they are displayed on a computer monitor. They are reproduced here as best as possible. You may need to darken the room lights and adjust the contrast and brightness on your monitor to appreciate some findings.

Case A:

This is a 15-month old male with fever, coughing, and tachypnea.

View Case A.

Interpretation of Case A

• Bilateral central pulmonary infiltrates, but most marked in the right middle and left lower lobes. The left lower lobe infiltrate is best seen on the lateral view inferiorly over the spine. The lungs are hyperaerated.
• Impression: Right middle and left lower lobe infiltrates.

Case B:

This is a 3 year old female whose parents do not speak English well. Her chief complaint is coughing and difficulty breathing. There is mild bilateral stridor on exam. Her cough sounds slightly bronchospastic, but not barking in nature.

View Case B.

Interpretation of Case B

• No infiltrates are noted. The right side is more lucent (darker) compared to the left. This is subtle and may be difficult to appreciate unless you step back and view the CXR from a distance. The right hemidiaphragm is slightly higher than the left hemidiaphragm, however, it should be higher than this. Both these findings suggest right sided hyperexpansion. More clinical history through a translator indicated that she was jumping on a bed while eating some food (thought to be meat), when she began choking. Since that time, she has experienced respiratory difficulty. Further radiographs revealed bilateral air trapping. Bronchoscopy revealed bilateral bronchial peanut fragment foreign bodies.
• Impression: Right sided hyperexpansion and air trapping. Possible bronchial foreign body.

Case C:

This is a two week old male infant who arrived in the E.D. with a history of noisy breathing and worsening respiratory distress. VS T36.7, P160, R60, BP 100/70. His color is dusky. His oxygen saturation is 86% in room air. Oxygen is applied and his color improves. His oxygen saturation is now 96%. He has diminished breath sounds bilaterally. There are moderately severe retractions.

View Case C

Interpretation of Case C

• There is hyperlucency of the left chest with a mediastinal and cardiac shift to the right. Although this may look like a tension pneumothorax, realize that such a large tension pneumothorax would generally be associated with hypotension, bradycardia, and persistent hypoxia (despite supplemental oxygen). Since this infant appears to have good cardiovascular function and his oxygenation improved with supplemental oxygen, one should not immediately jump to evacuating the left chest since he is currently stable.
• After carefully reassessing the situation and reexamining the CXR, it is evident that lung markings are present in the left chest. This represents a hyperexpanded lobe. The hyperexpansion is so severe that it compresses the remaining left lung and pushes the heart and mediastinum to the right, compressing the right lung as well.
• Impression: Left upper lobe hyperexpansion with mediastinal shift. Congenital lobar emphysema. This case is discussed in more detail in Volume 1, Case 9.

Case D:

This is a 3-month old female with fever and coughing.

View Case D.

Interpretation of Case D

• This is a dark film. It is best read using a hot light. To maximize visibility on the computer monitor, turn off the room lights and adjust the contrast and brightness controls on your monitor to maximize image quality. There is a faintly visible infiltrate in the right upper lobe. Subtle findings may be more difficult to appreciate on dark films.
• Impression: Right upper lobe infiltrate.

Case E:

This is a two month old male with a history of a VSD (taking digoxin) arriving in the E.D. for a possible seizure. His parents witnessed an episode of body stiffness, jerking of all extremities, and upward rolling of his eyes lasting one minute. An ambulance brought him to the E.D.

His exam was significant for a harsh grade III/VI systolic murmur. His lungs were clear. He was alert and active, and no neurologic abnormalities could be detected. He promptly had another generalized seizure in the ED which lasted five minutes. An IV could not be started during the seizure. After the seizure, he was not drowsy. An IV was started, and he was given IV lorazepam and phenobarbital.

View Case E.

Interpretation of Case E

• There is cardiomegaly with slightly prominent pulmonary vascularity suggesting a left to right shunt. An unexpected finding was the absence of a thymic shadow that one would expect to see in a 2-month old. A prominent thymus is usually visible in the upper mediastinum on the AP or PA view. On the lateral view, the space anterior and superior to the heart is usually occupied by the thymus in this age group. However, in this child, the thymic space is occupied by lung tissue.
• His laboratory studies were significant for hypocalcemia. Although his clinical presentation resembled a classic seizure, in retrospect, the hypocalcemia suggests that these episodes were symptomatic tetany.
• Impression: Cardiomegaly and absence of the thymic shadow. In conjunction with the VSD and hypocalcemia, this is most consistent with DiGeorge syndrome (thymic and hypoparathyroid aplasia or hypoplasia). This case is discussed in more detail in Volume 2, Case 2.

Case F:

This is a 16 year old male presenting to the emergency department with moderately severe acute wheezing. His oxygen saturation is 95% in room air. He is noted to be wheezing. He is given an albuterol aerosol and he is noted to improve, but his degree of aeration is still somewhat poor. He complains of mild chest pain.

View Case F.

Interpretation of Case F

• Both lungs are hyperaerated. There are vertical air densities seen in the upper mediastinum extending up into the soft tissues of the neck. This is evidence of air dissecting against the left border of the cardiac silhouette. There is no evidence of pneumothorax.
• Impression: Pneumomediastinum.
• In a pneumomediastinum, the lateral view will often show air dissecting along the trachea or free air may be visible in the space anterior to the heart in the thymic region. In this case, free air in the thymic region is visible, but it may be difficult to see it on your computer monitor. There are vertical oblique air densities in the thymic space anterior and superior to the heart on the lateral view. Darken the room and adjust the contrast and brightness on your monitor to see it best.

Case G:

This is a 10 year old male who came to the E.D. with a history of coughing and fever. Poor breath sounds were noted on the left.

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Interpretation of Case G

• The left lung is consolidated. This atelectasis results in a mediastinal shift to the left. There are air bronchograms evident over the left lung. On the original film, there is a suggestion of a 1.5cm cylindrical foreign body in the left mainstem bronchus. Further history revealed that he had "swallowed" a plastic bullet several days ago.
• Impression: Consolidation of the entire left lung with the suggestion of a foreign body in the left mainstem bronchus.

Case H:

This is an 11-month old female with a history of a previous pneumonia who now presents with fever and coughing. Mild wheezing and rales are noted on auscultation.

View Case H.

Interpretation of Case H

• There are small interstitial central pulmonary infiltrates.
• Impression: Small interstitial central pulmonary infiltrates most consistent with a viral pneumonia.

Case I:

This is a 6-week old male infant. His parents brought him to the E.D. because of coughing and congestion. He had a 20 minute episode of frequent coughing, but now seems to be better. He is feeding well. There is no history of fever or cyanosis. His vital signs are normal. Oxygen saturation is 100% in room air. Auscultation is clear.

View Case I.

Interpretation of Case I

• The upper mediastinum shows the usual prominent thymus for this age. The thymic shadow is larger on the infant's right than on his left. There is a density in the right upper lobe, but it is obscured by the thymus. Part of this density appears to be from the scapula, but on close inspection, there are densities suggesting infiltrates aside from the thymus and the scapula in the right upper lobe.
• Impression: Right upper lobe infiltrate or partial atelectasis.

Case J:

This is an 18-month old female with a history of prematurity and mild bronchopulmonary dysplasia. She arrives in the emergency department with a history of fever, coughing, and difficulty breathing. Coarse breath sounds and mild wheezing are noted on auscultation.

View Case J.

Interpretation of Case J

• There is a small area of atelectasis in the right middle lobe. This is best seen on the lateral view as an oblique flattened wedge shaped density over the heart. Instead of the normal triangular shape of the right middle lobe, it appears to be flat and compressed indicating atelectasis.
• Impression: Right middle lobe atelectasis.

Case K:

This is a 5-week old infant with a history of fever and coughing. He arrives in the emergency department with severe respratory distress. His initial CXR shows a small pneumonia. He is thought to have a staph aureus pneumonia because of his severe condition. He requires mechanical ventilation in an intensive care unit. During his second day of hospitalization, he suddenly becomes severely cyanotic, bradycardic, and hypotensive. He has good breath sounds bilaterally. This portable CXR (AP only) is obtained.

View Case K.

Interpretation of Case K

• There is a lucency visible surrounding the heart; representing air dissecting into the pericardium.
• Impression: Pneumopericardium
• Pneumopericardium is usually a serious emergency since it results in sudden cardiac tamponade. Immediate pericardiocentesis is required. This is a highly complication prone procedure since it may lacerate the heart and even if it temporarily relieves the tamponade, more air will continue to accumulate in the pericardial space resulting in recurrent tamponade. Because of reaccumulation of air, inserting a plastic catheter into the pericardium using an IV catheter over needle or the Seldinger technique, may be more effective at preventing reaccumulation of air and tamponade. If a surgeon is immediately available, a pericardial window procedure may be more efficacious immediately following pericardiocentesis.

Case L:

This is an 11-year old female with a history of fever and coughing for 5 days. VS T39.1 (oral), P122, R 20, BP 107/76. Oxygen saturation 99% in room air. Auscultation is significant for moist rhonchi in the left base.

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Interpretation of Case L

• There is a patchy infiltrate at the left lung base. This is seen on the lateral view obliquely over the heart and on the PA view as haziness in the left lower lung. The prominence of the right perihilar region is probably due to rotation. Note the asymmetry of the spinal column and the ribs. This rotation exposes more of the right hilum in the radiograph, making it appear more prominent.
• Impression: Patchy area of consolidation at the left lung base.

Case M:

This is a 12-year old female complaining of a headache and productive cough. Onset of fever last night to 39 degrees. Rales are noted in the left base.

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Interpretation of Case M

• There are infiltrates in the right middle and left lower lobes. The right middle lobe infiltrate is blurring the right heart border. It can also be seen on the lateral view as streakiness over the heart. The left lower lobe infiltrate is best seen on the lateral view posteriorly on the diaphragm. It can also be seen on the PA view as haziness in the lower lung on the left. The infiltrate in the right middle lobe was noted two years ago on a previous radiograph, and the possibility of a chronic infiltrate was raised.
• Impression: Right middle and left lower lobe infiltrates.

Case N:

This is a 9-year old male with a history of fever, headache, nausea, and coughing.

View Case N.

Interpretation of Case N

• There is a circular density in the right lung. This is the superior segment of the right lower lobe. Although this has the appearance of a mass, it is most likely an infectious process.
• Impression: Spherical consolidation in the right lower lobe (round pneumonia).

Case O:

This is a 20-year old male who arrives in the E.D. complaining of difficulty breathing. He also describes some mild chest pain. He is a poor historian, but does admit to smoking crack cocaine earlier in the day. Auscultation reveals a "friction rub" that occurs in synchrony with his heart rate. His pulses and perfusion are good.

View Case O.

Interpretation of Case O

• On the PA film, air is seen dissecting along the superior mediastinum bilaterally. These vertical air densities extend up into the soft tissues outside the pleural cavity. There is also air superimposed over the inferior aspect of the aortic arch. The lateral view shows air densities demarcating the thymus. You may have to darken the room and adjust the contrast and brightness controls on your monitor to appreciate this. The lateral view also shows vertical air densities outlining the trachea.
• Impression: Pneumomediastinum.
• Pneumomediastinum is commonly associated with substance abuse and other activities that involve a valsalva maneuver. The "friction rub" that was auscultated was not really a friction rub. This grating sound called Hamman's Sign is associated with pneumomediastinum. This case is discussed in more detail in Volume 1, Case 7.

Case P:

This is a 17-month old female with a history of fever and coughing. She is crying on exam making auscultation difficult. Oxygen saturation is 98% in room air.

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Interpretation of Case P

• There is a small subtle infiltrate in the left costophrenic angle. This is best seen on the PA view as an increased density where the ribs cross each other in the left lower lung near the costophrenic angle.
• Impression: Small infiltrate in the left costophrenic angle.