Infectious/Inflammatory

Case 56

Emergency & Trauma, Infectious/Inflammatory / , ,

This radiograph shows a soft tissue opacity in the left upper quadrant without bowel gas. The stomach bubble is oriented vertically and deviated toward the midline, suggestive of mass effect. This appearance is expected in the right upper quadrant where the liver occupies the majority of the space, but the left upper quadrant typically has stomach or bowel gas. The differential for this appearance is broad and includes mass, splenomegaly, and ascites (if the bowel is sufficiently decompressed). Further investigation with CT or ultrasound would be advised. The rest of the exam is unremarkable.

This patient went on to CT which showed marked splenomegaly. Give their young age and reported history of recent illness, this was presumed to be sequela of prior mononucleosis.

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Case 46

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

This radiograph demonstrates a right upper lobe consolidation most consistent with lobar pneumonia in this patient with a cough and elevated white count. The consolidation has poorly defined margins with the exception of the inferior margin, which is sharp and linear. This is due to the consolidation abutting the minor fissure. The position of the consolidation superior to the minor fissure definitively localizes it to the right upper lobe. Uncomplicated community acquired lobar pneumonia does not typically cross fissures. While malignancy is not entirely excluded, a mass would be unlikely to respect the fissural boundary without exerting mass effect.

The exam is otherwise unremarkable.

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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 mediastinal/hilar lymph nodes. This is usually due to a remote history of granulomatous inflammation. Sarcoidosis and fungal infections (in endemic areas) are common causes. The calcifications do not resolve but are of no clinical consequence. This patient reported a history of histoplasmosis, and the extent of the calcifications suggest it was a more advanced case. However, in areas of the United States where Histoplasma capsulatum is endemic, it is common to have a few calcified nodules and/or lymph nodes without a reported history of significant infection. The differential for calcified nodules does include a few more serious entities including calcified metastases (such as from osteosarcoma) and tuberculosis infection.

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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 shows hazy consolidation in the right lung base, with more subtle left lower lobe consolidation projecting over the heart. There is a displaced left mid-clavicular fracture. Lines and tubes include an endotracheal tube, an enteric tube, and an esophageal temperature probe which are all appropriately positioned. The distribution is typical for aspiration, with or without infection. Contusion is also a consideration in a trauma patient. In this case, the EMS report included witnessed aspiration which makes it the most likely etiology.

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