Age <30 – ChestDB.com

Case 50

Malignancy / Age <30, Cannonball Metastases, Metastasis, Metastatic Disease

This radiograph demonstrates numerous round nodules and masses in a young patient consistent with metastatic disease. These are sometimes referred to as “cannonball” metastases because of their large size and round shape. They are classically associated with renal cell carcinoma and choriocarcinoma, though other primary tumor metastases can also have a cannonball appearance. In young male patients in particular, the search for a primary tumor should include a scrotal ultrasound. In this patient, testicular cancer was identified on physical exam and imaging.

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Case 47

Normal & Variants / Age <30, Calcification, Cervical Rib, Congenital, Histoplasmosis, Nodule, Thoracic Outlet Syndrome

This radiograph demonstrates bilateral cervical ribs, right greater than left. They are congenital and may be of no clinical significance. In some individuals, it can cause or contribute to thoracic outlet syndrome by compressing the subclavian vein, artery, and/or nerve. Cervical ribs may be resected in these cases.

There is also an incidental small, dense (likely calcified) nodule in the right lower lung and a probable calcified right hilar lymph node. This patient lives in an endemic area for Histoplasma capsulatum. Remote infection is the most likely etiology.

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Case 43

Emergency & Trauma, Mediastinum / Acute Aortic Syndrome, Age <30, Portable, Traumatic Aortic Injury, Widened Mediastinum, Widened Vascular Pedicle

This previously healthy young patient presented to the emergency department after a motor vehicle collision. There is marked widening of the vascular pedicle and loss of the normal contour of the aortic arch. This finding is consistent with acute traumatic aortic injury. The lungs are clear and there are no radiographically evident fractures.

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Case 37

Normal & Variants / Age <30, Pectus Excavatum

This radiograph demonstrates a hazy right paramedian opacity with an indistinct right heart border. This is a typical radiographic appearance of pectus excavatum. A lateral radiograph or a prior CT (if available) could be used to confirm. The primary differential consideration would be a right middle lobe pneumonia or potentially a mediastinal mass if the sternal depression is severe enough to cause deformation of the mediastinal contours (not seen in this case).

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Case 36

ICU/Surgery, Infectious/Inflammatory, Lines/Tubes/Devices / Age <30, Central Venous Catheter, CVC, Empyema, Endotracheal Tube, Enteric Tube, Nodule (Cavitary), Pleural Effusion, Portable, Septic Embolism

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 35

Chronic & ILD, Mediastinum / Age <30, Eisenmenger Syndrome, Pulmonary Hypertension, Shunt

This radiograph shows severely dilated pulmonary arteries. The differential for this finding includes pulmonary hypertension, flow abnormalities from shunting or valvular disease, and connective tissue diseases, among others. This a young patient with Eisenmenger Syndrome, a condition resulting from a longstanding uncorrected left-to-right shunt. The shunt causes pulmonary hypertension, which eventually becomes so severe that the direction of flow through the shunt reverses resulting in significant hypoxemia.

The exam is otherwise normal.

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Case 34

Emergency & Trauma / Age <30, Atelectasis (Compressive/Passive), Central Venous Catheter, CVC, Kerley B Lines, Pleural Effusion, Portable, Pulmonary Edema

This radiograph demonstrates typical findings of pulmonary edema. The vessels are hazy with indistinct margins. Kerley B lines are seen peripherally. There are bilateral layering pleural effusions creating a gradient of opacification extending from the bases. Bibasilar opacities are silhouetting the diaphragm and the right heart border, representing a combination of pleural effusions and associated atelectasis.

A dual-lumen central venous catheter is also in place.

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Case 29

ICU/Surgery / Age <30, Pleurodesis, Pneumothorax, Pneumothorax, Subpulmonic, Wedge Resection

This radiograph demonstrates a left subpulmonic pneumothorax in the upright position. Typically pleural air would be expected to collect apically (anti-dependently) in this position. However, this patient has a history of wedge resection evident by the staple line seen in the apical left upper lobe. This was complicated by recurrent pneumothorax for which the patient underwent pleurodesis. The resultant pleural scarring is preventing the pleural air from rising, giving this appearance.

Other than the presence of EKG leads, the remainder of the exam is unremarkable.

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Case 23

Emergency & Trauma, Infectious/Inflammatory / Age <30, Asthma, Peribronchial Cuffing, Portable, Reactive Airway Disease

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 19

ICU/Surgery, Lines/Tubes/Devices / Age <30, Enteric Tube, NAVA, Neonatal Respiratory Distress Syndrome, Neurally Adjusted Ventilatory Assist, PIE, Portable, Premature Neonate, Pulmonary Interstitial Emphysema, RDS (Neonatal), Surfactant Deficiency Disorder

This radiograph is of a premature infant in the first week of life. The right lung demonstrates diffuse microatelectasis typical of Neonatal Respiratory Distress Syndrome (RDS), also known as Surfactant Deficiency Disorder, caused by insufficient surfactant production in the setting of prematurity (typically <35 weeks gestation). The left lung is hyperinflated relative to the right lung, with diffuse linear lucencies radiating from the hilum. This appearance is typical for Pulmonary Interstitial Emphysema (PIE), a condition secondary to barotrauma from ventilation seen in premature infants in the first weeks of life. An NG/OG tube terminates in the body of the stomach. A second tube, thicker and denser than the NG/OG, with multiple rounded lucencies along the distal aspect is also seen. This is a NAVA tube (Neurally Adjusted Ventilatory Assist), which detects electrical activity of the diaphragm to improve synchrony with the ventilator.

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