Volume 4, Case 5
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 of the findings.
This is a 16-month old male with coughing, wheezing, and tachypnea.
View Case A.
Interpretation of Case A
No acute infiltrates are seen. There is a faint vertical lucency paralleling the right mediastinal border see only on the PA view. No other vertical air densities are seen. This may be an artifact or this patient may have a small pneumothorax or a pneumomediastinum. A pneumomediastinum usually has other vertical air densities over the upper mediastinum on the PA view and over the thymic space on the lateral view. In this case, the thymic space is normal.
Impression: Right mediastinal lucency. This is mostly likely an artifact or possibly, a small right pneumothorax or pneumomediastinum.
This is a 9-month old male with fever and coughing.
View Case B.
Interpretation of Case B
This film is dark. Turn down the room lights and adjust the brightness and contrast on your screen. There is an area of density best seen on the lateral view posteriorly just above the diaphragm over the inferior vertebral body. This represents consolidation at the medial aspect of the left lung base posteriorly. On the lateral view, these vertebral bodies should progressively darken (become blacker) as you proceed inferiorly (T1 to T12). If one the vertebral bodies appears whiter than it should be, this is often due to an overlying soft tissue density such as an infiltrate or consolidation.
Impression: Subsegmental consolidation of the posterior segment of the left lower lobe.
This is a 2-month old female who is wheezing.
View Case C.
Interpretation of Case C
The diaphragms are flattened indicating bilateral hyperaeration. The lateral view demonstrates this best. Both diaphragms have lost the usual dome appearance. They are both flattened obliquely. Additionally, the lateral view shows the increased AP diameter. In small children, hyperaeration (flattened diaphragms) are best demonstrated on the lateral view as seen here.
There may be slight accentuation of the central lung markings suggesting a viral pneumonia.
Impression: Hyperaeration with accentuated central lung markings.
This is a 15-month old male with fever and coughing.
View Case D.
Interpretation of Case D
There is a density in the right upper lobe. This is not due to the scapula since the other side does not have this appearance. This is a patchy area of consolidation in the posterior portion of the right upper lobe.
Impression: Partial right upper lobe consolidation.
This is a 6-week old female presenting with fever and cold symptoms. Her temperature is 39 degrees rectally. She is feeding well.
Exam VS T39.1 (rectal), P125, R45, BP 75/35, oxygen saturation 98% in room air. She is alert and active. She is not toxic and not irritable. AF flat and soft. TM's normal. Oral clear. Neck supple. Heart regular without murmurs. Lungs are probably clear, but there may be some wheezing. Abdomen benign.
View Case E.
Interpretation of Case E
The lungs are hyperaerated. The diaphragms are flattened (most notably, on the lateral view). There is a density in the right upper lobe seen best on the PA view. The scapula can be visualized distinctly from this density. This is an area of consolidation or atelectasis in the posterior segment of the right upper lobe. This density is also evident on the lateral view in the superior posterior region.
Impression: Hyperaeration of the lungs with an area of consolidation or atelectasis in the posterior segment of the right upper lobe.
This is a 3-year old male with fever and coughing.
View Case F
Interpretation of Case F
There is a patchy area of consolidation in the posterior portion of the left lower lobe. The lateral view best demonstrates this as a density over the inferior vertebral bodies. As stated earlier, the appearance of the vertebral bodies should darken as one proceeds inferiorly. Note that the two most inferior vertebral bodies above the diaphragm are whiter than the vertebral bodies above them. This is due to an overlying consolidation that is clearly outlined when examining the radiograph carefully. This density is located behind the heart making it difficult to see on the PA view. However, an increased streakiness (density) is seen over the left inferior lateral heart border.
Impression: Segmental area of consolidation in the posterior portion of the left lower lobe.
This is a 3-year old male with fever and coughing. He is tachypneic. Crackles are heard on the left. No wheezing is heard, but he has a bronchospastic cough. There is no past history of asthma.
View Case G.
Interpretation of Case G
The central markings are accentuated. The lungs are otherwise clear.
Impression: Accentuated lung markings.
This is a 3-year old male with a history of a fever and coughing for one week. Rales are heard on the right.
View Case H.
Interpretation of Case H
The central markings are definitely accentuated. There is an infiltrate in the right middle lobe.
Impression: Bilateral central and right middle lobe infiltrates.
This is a 14-month old female with a past history of severe prematurity and chronic lung disease. She now has fever, coughing, and wheezing.
View Case I.
Interpretation of Case I
The pulmonary outflow tract is prominent. The central markings are accentuated and fluffy, more so on the right. This is evident on the PA view. However, the lateral view also demonstrates increased markings and fluffiness around the hilum. These findings are consistent with chronic lung disease and possibly suggestive of pulmonary hypertension.
Impression: Accentuation of the central markings. Chronic lung disease (bronchopulmonary dysplasia) and possible pulmonary hypertension.
This is an 14-month old male with a history of coughing and fever.
View Case J.
Interpretation of Case J
The PA view demonstrates a density in the left upper lobe. The lateral view demonstrates a triangular density in the upper lung and a flat density positioned obliquely over the heart. The upper density is an area of consolidation in the posterior apical segment of the left upper lobe. The lower density over the heart is a consolidation of the lingula. Note that the PA view does not demonstrate any densities on the right in the area of the right middle lobe. An infiltrate in the lingula usually obscures the left heart border (not so obvious in this case).
Impression: Left upper lobe and lingula consolidation.
This is a 4-month old with respiratory distress and diminished breath sounds on the right.
View Case K.
Interpretation of Case K
PA inspiratory and expiratory views are shown here. The inspiratory view demonstrates hyperexpansion of the right hemithorax. The right hemithorax is blacker than the left. The right hemithorax is also bigger than it should be. Lung markings are evident throughout both lungs making this incompatible with a pneumothorax. The expiratory view shows satisfactory emptying of the left lung, but persistent hyperexpansion of the right lung.
The diagnosis of foreign body is considered, but the typical age group for a bronchial foreign body is 2 years and above. This child's past history is significant for complaints of abnormal breathing in the past.
Closer examination of the radiographs on the right show a density in the upper medial hemithorax (small density compressed against the upper mediastinum). This is probably a compressed right upper lobe.
Impression: Hyperexpansion of the right middle and right lower lobes raising the possibility of an obstruction in the intermediate right bronchus.
This child is ultimately found to have a congenital lobar emphysema of the right middle lobe. The topic of lobar emphysema is discussed in more detail in Case 9 of Volume 1, Respiratory Distress - That's a Tension Pneumothorax Isn't It?
This is a 4-month old female with a history of fever and coughing.
View Case L.
Interpretation of Case L
The PA view looks fairly normal except for blurring of the left medial diaphragm. The lateral view demonstrates an infiltrate superimposed over the inferior aspect of the spine just above the diaphragm. The vertebral bodies inferiorly should be blacker than the vertebral bodies above them. In this case, the inferior vertebral bodies are whiter indicating the presence of an overlying soft tissue density. It is hard to appreciate any infiltrate on the PA view since it is behind the heart on the left.
Impression: Small infiltrate in the posterior portion of the left lower lobe.
This is a 6-week old female with a history of fever and cold symptoms.
View Case M.
Interpretation of Case M
There is a faint density in the right upper lobe on the PA view. The lateral view also demonstrates this density in the upper lung posteriorly. The diaphragms are flattened indicating hyperaeration.
Note the spherical density overlying the middle portion of the right clavicle. This is callus formation of a healing right clavicle fracture. Healing clavicle fractures in this age group are usually due to fractures occurring during birth. While most of these are diagnosed on routine examination at birth, some of these are not. Such a finding on a chest radiograph may be the first indication of a clavicle fracture. This problem is benign and does not require any special care at this point. Consider the possibility of child abuse if the history or the appearance of the fracture does not suggest that it was caused by the birthing process.
Impression: Hyperaeration of the lungs with an area of consolidation or atelectasis in the posterior segment of the right upper lobe. Healing right clavicle fracture.
This is a 17-month old male with a history of fever, coughing, and respiratory distress.
View Case N.
Interpretation of Case N
There is an obvious consolidation of the right upper lobe. Although both costophrenic angles are sharp, note the abnormal contour of the right hemidiaphragm. The diaphragm should have a domed appearance (normal) or a flattened appearance (hyperexpanded lungs). But the right hemidiaphragm here has an unusual contour where it is flat medially, then it sharply dips downward laterally. The diaphragms should normally be highest in the middle (domed appearance) or highest medially (flattened appearance).
Case 4 of Volume 2 describes a case of pleural effusions. The diaphragms in this case also had unusual contours where the lateral portions of the diaphragms were higher than the medial or center portions of the diaphragms. This finding is associated with the presence of a pleural effusion even if the costophrenic angles are sharp.
This patient's PA radiograph demonstrates a substantial consolidation of the right lung with an abnormal diaphragm contour. Although the lateral aspect of the diaphragm is not truly the highest point of the diaphragm, this is still suspicious for a pleural effusion. Subsequent radiographs of this patient's lungs demonstrated the presence of a pleural effusion.
Looking back at the lateral view, the posterior costophrenic angle may be blunted suggesting a pleural effusion, however, this is where the film is cut off, thus, this appearance may be an artifact.
This is a 2-month old male with fever, noisy breathing, and tachypnea. His breath sounds are slightly coarse.
View Case O.
Interpretation of Case O
The PA view demonstrates moderate cardiomegaly and accentuation of the central markings. These findings are most consistent with early congestive heart failure rather than a viral pneumonia. This PA view is slightly rotated making this radiograph more difficult to interpret. The prominent right side of the heart, was initially felt to be due to the rotation. However, it is too large to be due to rotation alone.
Impression: Early congestive heart failure.
An echocardiogram confirmed the presence of congestive heart failure due to congenital heart disease. This case is discussed in more detail in Case 3 of Volume 4, Tachypnea in a 2-Month Old.
This is a 3-year old male with frequent colds who now presents with fever and coughing.
View Case P.
Interpretation of Case P
The PA view shows both lower lung fields to be denser than the upper lung fields. This is more evident on the left than on the right. The apex of the heart is displaced outward suggesting the possibility of early congestive heart failure.
However, in this instance, the findings above are all due to a slightly suboptimal inspiratory effort. Because of the poor inspiration, the central markings are crowded. The diaphragm is at the level of the 9th rib. Ideally, the 9th posterior rib should be above the diaphragm.
Impression: No definite acute cardiopulmonary disease. Borderline suboptimal inspiration.