Showing posts with label chest x ray. Show all posts
Showing posts with label chest x ray. Show all posts

Tin Man Syndromes or Ectopia cordis Interna

By Dr Deepu

The following case was reported by Dr Matt Skalski in radiopedia.
The chest X ray was done on a person for employment screeing. The chest X ray showed no heart. Rare isn't it. On enquiry he didnt have any symptoms other than gastric reflux. Then a CT was done which showed heart inside the stomach.
This was the X ray picture

Now let us compare this X ray with a normal one.
The heart shadow is absent in the previous X rays compared to this.
This condition is called as Tin Man syndrome or Ectopia cardiac internalis, meaning heart is present at a different site inside the body.
Let us have a look at the CT films of the abdomen.






The CT images shows heart in the  abdomen.
Now let's know the historical aspects of TIN MAN syndrome which is extremely rare.


This picture is  of Da Vincis organ newotks of the thoracoabdominal cavity.There remains debate as to whether Leonardo Da Vinci's "Organ networks of the thoracoabdominal cavity" illustration (c.1502) was based off a corpse with ectopia cordis interna, or whether his depiction of the heart's location was a deliberate distortion of reality. Most legitimate scholars believe Da Vinci created the work as a flight of anatomical fancy.           
The first ever description of the condition in the medical literature was in a controversial monograph submitted to the Royal Society in 1874 by Dr. Nohear Lubdub. Entitled "An unusual case of ectopia cardia epigasticum in a Haryana boy", the monograph was later retracted when accusations were made that the images accompanying the text had been doctored.
It was not until 1908 that Dr Lubdub's work was vindicated when existence of the condition was confirmed during the early years of chest radiography. Unfortunately, Dr Lubdub had fallen into a deep depression following his expulsion from the Royal Society, only occasionally seen wandering the streets of Chandigarh mumbling "and yet it beats". His death was unrecorded. 

Disclaimer : this was a April Fool Case published in Radiopedia.org and is Imaginary.
Case courtesy of Dr Matt Skalski, 

Radiopaedia.org. From the case rID: 33437

Signs in chest radiology- The hilum overlay sign

By Dr Deepu


The hilar overlay sign is another sign described by Felson.The hilum overlay sign refers to an appearance on frontal chest X ray of patients with a mass at the level of the hilum which is in fact either anterior or posterior to the hilum.




When a mass arises from the hilum, the pulmonary vessels will be in contact with the mass and hence their silhouette is obliterated. The ability to see and trace the edges of the vessels through the mass implies that the mass is not contacting the hilum, and is therefore either anterior or posterior to it. 


Most of these masses usually are found to be in the anterior mediastinum.

want to read more in chest radiology??? Have a look at the following pages

Signs in chest radiology- The silhouette Sign

By Dr Deepu
Silhouette sign/loss of silhouette sign/ loss of outline sign.
I was always confused with the silhouette sign for its hidden meaning and failure to decode it by many medical students. So, I thought it would be apt to unravel it so that it could be handy for many medical students.
One of the most useful signs in chest radiology is the silhouette sign. This sign was described by Dr. Ben Felson. The silhouette sign is in nothing but  elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung. For instance, if an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border. The sign is commonly applied to the heart, aorta, chest wall, and diaphragm. The location of this abnormality can help to determine the location anatomically. 

Just go through the X Ray to know the  various structures seen in the chest x ray.

Let me explain this with this image.
What do we see???
There is plastic bottle which is surrounded by air, the margins of the shadow is very  well demarcated from the surrounding air.

First scenario: There are two bottles, made of same material, placed apart from each other. The shadows appears separate from each other. Let us consider the right bottle to be the heart and the air surrounding the bottle as lung. The left bottle as a mass, since they are far from each other, the border of both  is visible clearly.

Second scenario: Here we see the bottles are touching each other at two points and there is no gap in between and if we look at the shadow, we cannot differentiate between the two shadows, they appear like a single opacity at the upper and lower ends.


For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe, lower aspect of the oblique fissure, anterior mediastinum, and anterior portion of the pleural cavity.
This contrasts with an opacity in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an obliteration of the heart border. Therefore both the presence and absence of this sign is useful in the localization of pathology.

want to read more in chest radiology??? Have a look at the following pages
Chest Radiology
Signs in Chest Radiology

signs in chest radiology Bulging Fissure Sign

By Dr Deepu
Bulging Fissure Sign

The bulging fissure sign, it represents expansive lobar consolidation causing fissural bulging or displacement by copious amounts of inflammatory exudate within the affected parenchyma, seen in a chest x ray. It is classically associated with right upper lobe consolidation due to Klebsiella pneumoniae , any form of pneumonia can manifest the bulging fissure sign.  The prevalence of this sign is decreasing,because of prompt administration of antibiotic therapy to patients with suspected pneumonia . The bulging fissure sign is also less commonly detected in patients with hospital-acquired Klebsiella pneumonia than in those with community-acquired Klebsiella infection .
   Other diseases that manifest a bulging fissure
 any space-occupying process in the lung, such as
pulmonary hemorrhage,
 lung abscess, and
 tumor
want to read more in chest radiology??? Have a look at the following pages

Plombage - An Obsolete Technique of Historical Importance in treating TB

By Dr Deepu
Chest X Ray of Plombage using Lucite Balls

CT Thorax of the same Patient


Plombage was a surgical method used prior to the introduction of anti-tuberculosis drug therapy to treat cavitary tuberculosis of the upper lobe of the lung. The term derives from the Latin word "plumbum" (lead) and refers to the insertion of an inert substance in the pleural space. The technical medical term for plombage is extraperiosteal or extrapleural pneumonolysis.
The underlying theory of plombage treatment was the belief that if the diseased lobe of the lung was physically forced to collapse, it would heal quickly. There were positive results in tuberculosis therapy following plombage in the decades of the 1930s, 40s and early-50s. However, with the introduction of drugs which were effective in destroying the tuberculosis bacterium (Mycobacterium tuberculosis), plombage treatment fell into disfavor. In addition, complications of plombage began to appear in patients who had been so treated. These complications included hemorrhage, infection and fistulization  of the bronchus, aorta, esophagus and skin.
The technique involved surgically creating a cavity underneath the ribs in the upper part of the chest wall and filling this space with some inert material. A variety of substances were typically used and included air, olive or mineral oil, gauze, paraffin wax, rubber sheeting or bags and Lucite balls. The inserted material would force the upper lobe of the lung to collapse.

NEJM LINKS FOR LUCITE BALLS

Spotter- Give your diagnosis

By Dr Deepu
Observe the images properly and answer the following questions.
1. What is your diagnosis?
2. What is the radiological appearance?
3. When and why it is done?


See Answer 
Here

NEJM LINKS FOR LUCITE BALLS
link1
Link2



Image courtesy: Dr Shravan.

MELTING ICE(CUBE) SIGN

By Dr Deepu

 The melting ice(cube) sign describes the resolution of. pulmonary haemorrhage following pulmonary embolism. 
When there is pulmonary haemorrhage without infarction following PE, the typical wedge-shaped, pleural-based opacification (Hamptons Hump) resolves within a week while preserving its typical shape. It is named due to its resemblance with a melting ice cube.

1. Webb WR, Higgins CB. Thoracic Imaging: Pulmonary and Cardiovascular Radiology, North American Edition. Lippincott Williams & Wilkins. (2010) ISBN:1605479764. 


Suggested Reading
1. Chest X Ray Part 1- Normal Anatomy And ItsVariants

SPOTTER : GIVE YOUR DIAGNOSIS

Pulmonary Medicine Blog By Dr Deepu

Mr X came to the out patient department with hemoptysis since 2 weeks, and chest pain in the right upper part anteriorly since 2 weeks. On questioning he further revealed weight loss since 2 months.
Chronic smoker with 60 pack years.
Examination revealed grade 3 clubbing. Clinical examination was normal.
This Chest X ray was taken.



1. What does the CXR show?
2. What is the differential diagnosis ?
3.  Diagnosis more likely?

Grand Rounds - Opaque hemithorax.

Pulmonary Medicine Blog By Dr Deepu

Grand Rounds:

This patient an elderly lady presented to us with breathlessness and cough eith sputum with increased sputum in right lateral position. Spo2 was 89% 
Examination revealed trachea deviated to left. Apicak impulse felt in left axilla 5th Ics. Breath sounds diminished on left with added crepitations on left side.
This X ray was taken in emergency room.

 CT confirmed fibrosis of left lung.
Complete white out(opacification) of the hemithorax on CXR has a limited number of causes.
 The differential diagnosis can be zeroed on with one simple observation - the position of the trachea. 
Is it central, pulled or pushed from the side of opacification?
  • pulled trachea : pneumonectomy, total lung collapse, pulmonary fibrosis,pulmonary agenesis
  • central: consolidation, mesothelioma, collapse with effusion. Lung mass 
  • pushed: pleural effusion, diaphragmatic hernia.

Radiology- chest X Ray Spotters.

Pulmonary Medicine Blog By Dr Deepu

spotter 1.
A middle Aged male who is HIV+ presents with a cough of 3 months and cachexia. Auscultation reveals crepitations b/l . Differentials???


Clinical Case - Give Your Diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu
An elderly female came to the outpatient department with a history of cough since 2 weeks minimally productive sputum, she also give history of increased breathlessness since 3 weeks, the symptom of breathlessness being present since three years, she also complains of decreased sleep due to productive cough, and a known hypertensive since 5 years.
  Clinical examination reveals pitting pedal edema and bilateral basal crepitations and no other significant clinical findings were present.
Investigations revealed a total count of 13000 and this chest x ray. EKG was normal. What could be the differential diagnosis????

Spotter : Identify the radiological sign in chest X ray.

Spotter for you: What is your Diagnosis?? What are the differentials and source of such condition.

Chest X Ray- The Diaphragm is unique and provides clue to your diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu

There are a few things which beginners often miss in a chest x ray, one among those is failure to comment on the diaphragms.
Today I am going to discuss importance of tracing diaphragm in a chest X ray with an example.
          Normal diaphragm in a chest X ray has the following characteristics
1.     Trace the diaphragm on right and left
2.     The right diaphragm is usually placed between the fifth and the sixth Rib in the mid clavicular line, It can be seen upto middle of sixth and seventh rib.
3.     The Diaphragms are usually not at the same level on the frontal , erect , inspiratory chest X rays, but they are usually within one rib intercostals space height ( roughly 2 cm) of each other.
4.     The left diaphragm is usually lower than right.
5.     The costophrenic angles should be sharp, making an acute angle.
6.      If the left hemidiaphragm is equal to Right or higher than Right or Right diaphragm is higher than left by more than 3 cms, Causes of diaphragmatic elevation should be considered.
The causes of elevated hemidiaphragm are
1.            Causes above the diaphragm- decreased lung volume due to Lung Collapse, lobectomy, pneumonectomy , fibrosis and pulmonary Hypoplasia
2.            Causes in the diaphragm- Phrenic nerve palsy , diaphragmatic evantration
3.            Causes below the diaphragm- abdominal malignancy, subphrenic abscess, distended   hollow viscus.
After knowing the cause I want to discuss with you a chest x ray where the subtle change in the diaphragm was missed.
Before we proceed Read the chest X ray

 The Chest X ray showed a subtle change in Diaphragm
1. Both the diaphragms are at the same levels.
2. The air shadow underneath the left diaphragm is more prominent.
3. The patient was not evaluated further because chest X Ray appeared normal and sent home with conservative treatment for COPD. 
He came back to our center with hemoptysis one month later referred from the center which treated him initially, a second Radiograph was performed. study the Chest X Ray before proceeding further.  


The chest X ray  now shows features of full blown disease, the hilum is prominent with CORONA RADIATA SIGN suggestive of bronchogenic carcinoma, The left Diaphragm is now placed higher compared to right. Further HR and CECT revealed a tumor in the Left Main bronchus with lymph node metastasis. With Bronchoscopy the diagnosis of squamous cell carcinoma was made.

With this I will end this post, requesting everyone to look at any subtle changes in diaphragm which if ignored may cause some grave diagnosis at a later date.

Basics Of Chest X Ray Part-6, The Lungs, Pleura And The Chest Wall.

Pulmonary Medicine Blog By Dr Deepu

Lung abnormalities mostly present as areas of increased density, which can be divided into the following patterns:

Consolidation
Atelectasis
Nodule or mass - solitary or multiple
Interstitial
Less frequently areas of decreased density are seen as in emphysema or lungcysts.

BEST BOOK FOR CHEST RADIOLOGY
 


Chest X-Ray - Lung disease.
Consolidation

Atelectasis


Nodule - Masses

Solitary pulmonary node 
Interstitial pattern


Interstitial lung diseases will be discussed in coming posts.

Pleura

Pleural fluid

It takes about 200-300 ml of fluid before it comes visible on an CXR (figure).
About 5 liters of pleural fluid are present when there is total opacification of the hemithorax.

Total opacification of the right hemithorax in a patient with pleuritis carcinomatosa on both sides.
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On the right there is only some air visible in the major bronchi creating an air bronchogram within the compressed lung.
Pleural fluid may become encysted.


Here we see fluid entrapped within the fissure.
This can sometimes give the impression of a mass and is called 'vanishing tumor'.

Pneumothorax

The table lists the most common causes of a pneumothorax.
The other cystic lungdisease which causes pneumothorax is Langerhans cell histiocytosis (LCH) which is seen in smokers.
Study the CXR.

There are two important findings.
The retracted visceral pleura is seen (blue arrow) which indicates that there is a pneumothorax.
There is a horizontal line visible (yellow arrow).

Normally there are no straight lines in the human body unless when there is an air-fluid level.
This means that there is a hydro-pneumothorax.
When a pneumothorax is small, this air-fluid level can be the only key to the diagnosis of a pneumothorax.
Study the CXR.
There are 3 important findings.
Notice that the mediastinum is slightly displaced to the left.
Does this mean that there is a tension pneumothorax?
Do you have an idea about the cause of the pneumothorax?
There is a hydropneumothorax.

Notice the air-fluid level (blue arrow).
The upper lobe is still attached to the chest wall by adhesions.
Maybe this patient was treated for a prior pneumothorax.
There is a lung cyst in the upper lobe (red arrow).
So we can assume that the pneumothorax has something to do with a cystic lung disease.
Since this patient is a woman, lymphangioleiomyomatosis (LAM) is a possible diagnosis.
LAM is a rare lung disease that results in a proliferation of smooth muscle throughout the lungs resulting in the obstruction of small airways leading to pulmonary cyst formation and pneumothorax.
LAM also occurs in patients who have tuberous sclerosis.
Study the CXR.

What is your diagnosis?
This is not a pneumothorax but a skin fold.
The radiography was performed supine with a CR cassette inserted underneath the patient, which resulted in a skinfold.
Notice that there are lung markings beyond the apparent pneumothorax.
Here two CXRs of another patient with obvious skinfolds.
Recognition of a pneumothorax depends on the volume of air in the pleural space and the position of the body.
On a supine radiograph a pneumothorax can be subtle and approximately 30% of pneumothoraces are undetected.
A sign to look for is the 'deep sulcus sign'.
It represents lucency of the lateral costophrenic angle extending toward the hypochondrium (Figure).
The image is of a patient in the ICU who is on mechanical ventilation. There was an acute exacerbation of the dyspnea.
There is a deep sulcus sign on the left
Notice that the left hemidiaphragm is depressed.
This is an important finding since it indicates a tension pneumothorax.
The image on the below is after insertion of an intercostal drain.
Notice that the diaphragm has regained its normal appearance.
Pleural opacities
The table lists the most common causes of pleural opacities.

Pleural plaques
The CXR shows multiple opacities.

They have irregular shapes and do not look like a lung masses or consolidations.
Some of these opacities are clearly bordering the chest wall (red arrows).
All these findings indicate that we are dealing asbestos related pleural plaques.
Asbestos related pleural plaques are usually:
bilateral and extensive.
covering the dome of the diaphragm.
Unilateral pleural calcifications are usually due to:

infection (TB)
empyema
hemorrhagic
Pleural hematoma

These images are of a patient, who had a pleural opacity after a chest trauma.
It was believed to be a hematoma and resolved spontaneously.

Chest wall

Ribfractures
The most common identified chest wall abnormalities are old ribfractures.
The CXR shows many rib deformities due to old fractures.

When a rib fracture heals, the callus formation may create a mass-like appearance (blue arrow).

Sometimes a CT is necessary to differentiate a healing fracture from a lung mass.
Notice the large lung volume and the enlarged pulmonary vessels.
Probably we are dealing with pulmonary arterial hypertension in a patient with COPD.
The second most common chest wall abnormalities that we see on a CXR are metastases in vertebral bodies and ribs.

Notice the expansile mass in the posterior rib on the right.

Abdomen

The most obvious finding on this CXR is free air under the diaphragm.
This finding indicates a bowel perforation, unless when the patient had recent abdominal surgery and there is still some air left in the abdomen, which can stay there for several days.
There is another subtle finding in the left upper lobe.
A subtle density projecting over the first rib - hidden area - proved to be a lungcarcinoma.
Here another patient with free abdominal air.

Notice the very thin regular line which is the diaphragm (arrow).