Infectious/Inflammatory

Case 36

ICU/Surgery, Infectious/Inflammatory, Lines/Tubes/Devices / , , , , , , , , ,

This radiograph demonstrates typical findings of septic emboli. There are multiple bilateral nodules, many with cavitation. Metastatic disease would be within the differential for this finding, though in practice the clinical history is typically quite useful to distinguish between these two entities; In this case, the patient is young with a history of drug abuse (suggesting endocarditis as a source) and presents with sepsis. In addition, this patient has medium bilateral pleural effusions. In the setting of septic emboli this is concerning for empyema. CT is usually confirmatory.

Support devices include a central venous catheter in the right internal jugular vein, an endotracheal tube in the mid trachea, and an enteric tube entering the stomach and terminating inferiorly beyond the border of the study.

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Case 32

Infectious/Inflammatory / , ,

This radiograph demonstrates a lingular consolidation concerning for pneumonia. The location of the consolidation can be localized to the lingula even without a lateral radiograph using silhouette sign. There is a loss of sharpness and definition, or “silhouetting,” of the left heart border at the location of the consolidation, indicating that the consolidated lung makes direct contact with the left heart. Anatomically the pulmonary lobe that has the greatest area of contact with the left heart is the left upper lobe, specifically the inferior left upper lobe (the lingula), making the silhouette sign a reliable method of localization. The lingula is a relatively common location for pneumonia.

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Case 31

Chronic & ILD, Infectious/Inflammatory / , , ,

This radiograph demonstrates multiple bilateral calcified pulmonary nodules and hilar lymph nodes. The most common cause of this finding by far is granuloma formation secondary to healed infection. The calcifications typically do not resolve, but are of no clinical consequence. The infection in many cases is mild or subclinical. In areas of the United States where Histoplasma capsulatum is endemic, it is common to have one or more calcified granulomas without a history of significant infection. In this case, the patient did report a history of histoplasmosis. The exam is otherwise unremarkable.

The differential includes calcified metastasis (such as from osteosarcoma), nodular sarcoidosis, and miliary TB among others, though these are significantly less common.

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Case 23

Emergency & Trauma, Infectious/Inflammatory / , , , ,

This is a radiograph demonstrates peribronchial cuffing, which is increased density around the bronchioles when viewed end-on. This may represent thickening of the wall itself or fluid around the wall due to lymphatic congestion. The finding is nonspecific and can be seen in pulmonary edema, infectious and inflammatory bronchiolitis, and reactive airway disease. This particular case was a toddler with a previous diagnosis of asthma who presented to the emergency department with an acute asthma exacerbation.

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Case 18

Emergency & Trauma, Infectious/Inflammatory / , , , , , , ,

This radiograph demonstrates obvious consolidation in the right lower lung field, with more subtle retrocardiac left lower lobe consolidation. There is a displaced left mid-clavicular fracture. Lines and tubes include an endotracheal tube, an enteric tube, and an esophageal temperature probe. Without additional history, the lung findings are not specific. The distribution is typical for aspiration, though infection is also high on the differential. Contusion is also a consideration in a trauma patient. In this case, the EMS report included witnessed aspiration which makes it the likely etiology.

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