1. HOW READ CHEST XR -4
ANAS SAHLE ,MD

2. Brief review

3. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
Homo
Densityinfiltratio Heterogenous Centralperiph Silhouet
n
Wellill defined Zone eral
Necrotic sign
MEDIASTINAL
Central deviasionwided
COSTO-PHRENIC ANGEL
Freeoblitern
OTHER
Bone soft tissuediaphragm

4. Consolidation
Infection
causes Non-infection causes
Broncho-
WEGNER Cardiac
Pneumonia Lymphoma alveolar COP Sarcoid
disease failure
carcinoma

5. Abscess
1. Cavitating infective consolidation.
2. Single or multiple lesions.
3. organisms.
1. Bacterial (Staphylococcus aureus, Klebsiella, Proteus,
Pseudomonas, TB and anaerobes).
2. fungal pathogens are the most common causative
4. ‘Primary’ lung abscess – large solitary abscess without
underlying lung disease is usually due to anaerobic bacteria.
5. Associated with aspiration and/or impaired local or systemic
immune response (elderly, epileptics, diabetics, alcoholics
and the immunosuppressed)

6. Radiological features
• Most commonly occur in the apicoposterior
aspect of the upper lobes or the apical
segment of the lower lobe.
• CXR may be normal in the first 72 h.
• CXR – a cavitating essentially spherical area of
consolidation usually>2 cm in diameter, but
can measure up to 12 cm.
• There is usually an air-fluid level present.

7. Differential diagnosis
• Bronchopleural fistula – direct communication
with bronchial tree. Enhancing split pleural layers
on CT.
• Empyema - enhancing split pleural layers,
forming obtuse margins with the lung on CT.
• Primary or secondary lung neoplasms (e.g.
squamous cell carcinomas)
• these lesions can run a slow indolent course.
• Failure to respond to antibiotic therapy
should alert the clinician to the diagnosis.
• TB (usually reactivation) – again suspected
following slow response to treatment.

8. Case-1
• This was a 48-year-old male with fever of one
week’s duration.
• He was extremely ill and hypotensive
requiring inotrope therapy.

9. cxr

10. POSITION •AP CXR
QUALITY •Poor Technical Quality
•Bilateral patchy ill defined nodules
•Diffused but Most in middle ,lower
LESION zone .
•Peripheral region.
•Central trachea and mediasteinal?
MEDIASTINAL
•Hazy costo-phrenic angels.
ANGELS
•NO
OTHER

11. discussion
• This patient actually has Klebsiella bacteremia.
• In parts of South-East Asia, Burkolderia
pseudomallei may result in the same CXR
appearance.
• The other important etiologic agent is
Staphylococcus aureus bacteremia.

12. Case-2
• This patient presented with cough and fever
of one month’s duration.
• She is a known case of COPD with a past
history of surgery to the left lung.

14. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(PENETRATION)
•WELL defined necrotic round density
(cavitary) .
LESION •In middle zone at right hilum (apical
•Hazy density at right lower zone
RLL)
(bronchogram)
•Central trachea and mediasteinal?
MEDIASTINAL
•FREE costo-phrenic angels.
ANGELS
•Fracture at posterior 4-5 ribs.
OTHER

15. discussion
• The causes of lung cavities include :
– primary lung cancer (typically Squamous cell)
– tuberculosis.
– Klebsiella.
– Staphylococcus aureus (usually multiple).
– Anaerobes.
– Mycetoma.
– Wegener’s granulomatosis.
– rheumatoid nodule.
– and pulmonary infarction.
• Lesions in the upper lobe and apical segment of the
lower lobes are typical of pulmonary tuberculosis.

16. Case-3
• A young male with acute myeloid leukemia
underwent a bone marrow transplant.
• This was complicated by relapse of the
leukemia and persistent neutropenic fever.
• A CXR two months ago was normal

18. POSITION •AP CXR
•Poor Technical Quality
QUALITY •(PENETRATION,ROTATION?)
•Triangular homogenous density,it,s
base at chest wall (bronchogram),other
LESION well defined nodule at right upper zone, ill
defined nodule at left upper zone.
•Hazy density at left lower zone
obscured left heart border.
MEDIASTINAL •Central trachea and mediasteinal?
ANGELS •FREE costo-phrenic angels.
•No
OTHER

19. discussion
• The CXR shows a right upper lobe mass, which is wedge shaped
with the apex towards the hilum. This shadow is suggestive of a
pulmonary infarct.
• In addition, the left upper lobe shows a small nodule at the
periphery.
• The fact that CXR recently was normal makes a severe
overwhelming infection very likely.
• The CT demonstrated two additional findings. The right upper lobe
mass has a necrotic center and a surrounding halo.
• This is the classic “halo sign” (ground glass change adjacent to
central dense consolidation) around the right upper lobe mass.
• The halo is thought to represent edema or hemorrhage due to
infection by angiotrophic organisms, the most common being
Aspe.rgillus fumigatus

20. Case-4
• patient was admitted for severe acute
pancreatitis.
• A few days into the admission, the patient
became very tachypneic and required
intubation and mechanical ventilation.

22. POSITION •AP CXR
•Poor Technical Quality
QUALITY •(PENETRATION,ROTATION?)
•Bilateral hazy opacites at lower zone
,perihilar ill defined
nodule?(bronchogram?)
LESION •May obscured right hemidiaphragm
•No kerly B line no cardiomegaly.
MEDIASTINAL •Central trachea and mediasteinal?
ANGELS •Hazy left costo-phrenic angels.
•No
OTHER

23. discussion
• These are features of ARDS.
• The common causes of ARDS include:
– septic conditions like severe pneumonia,
– multiple fractures,
– massive blood
– transfusion,
– near drowning,
– and pancreatitis.

24. CASE-5
• An 80-year-old male presented with massive
hemoptysis and was intubated.
• He gave a past history of being treated for
tuberculosis many years ago.

26. POSITION •AP CXR
•Poor Technical Quality
QUALITY •(PENETRATION,ROTATION?)
•Cavitation opacity .
•At right upper zone extend to apex.
LESION •Ball density inside it, and gas crescent
above it.
MEDIASTINAL •Central trachea and mediasteinal?
ANGELS •Free costo-phrenic angels.
•No
OTHER

27. Discussion
• The CXR shows a right upper lobe ball within a cavity (air crescent
sign) pathogmonic of a mycetoma (also called aspergilloma).
• A lateral decubitus X-ray may demonstrate the fungal ball shifting
position.
• In this condition, a preformed cavity becomes colonized, usually by
the fungus Aspergillus fumigatus.
• Cavitary disease may be secondary to:
– fibrotic lung disease, e.g:
• . previous tuberculosis,
• sarcoidosis,
• ankylosing spondylitis.
• Massive hemoptysis can result and bronchial angiogram with
embolotherapy (using coils or gel foam) is temporizing.