Age 31-60 – ChestDB.com

Case 48

Lines/Tubes/Devices / Age 31-60, Bravo Device, Gastroesophageal Reflux Disease, GERD, Wireless pH Monitoring Device

This radiograph demonstrates an in situ wireless pH monitoring device, also called a Bravo device. It is placed by an endoscopist and continuously monitors the pH level in the esophagus, wirelessly transmitting the data to an external receiver worn around the patient’s waist for up to 96 hours. This allows for quantification of gastroesophageal reflux disease (GERD) over the recording interval. The device is designed to eventually detach, pass through the digestive tract, and be flushed down the toilet.

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Case 46

Emergency & Trauma, Infectious/Inflammatory / Age 31-60, Consolidation, Infection, Lobar Pneumonia, Pneumonia

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 45

Lines/Tubes/Devices, Normal & Variants / Age 31-60, Dual Chamber Pacemaker, Pacemaker, Persistent Left SVC

This radiograph demonstrates unusual but ultimately inconsequential pacemaker lead positioning. A dual chamber pacemaker generator pack projects over the left hemithorax. The right ventricular lead takes the expected course through the left brachiocephalic vein, superior vena cava, right atrium, and tricuspid valve and terminates in the expected position of the right ventricle. The right atrial lead, however, courses to the left of the aorta. There are no secondary signs to suggest an inadvertent extravascular course. The best explanation for this appearance is a persistent left superior vena cava. This is a normal variant and connects the left subclavian vein to the coronary sinus. Ultimately, the lead ends up in the right atrium. It is not clear in this case why this positioning was chosen rather than placing both leads in the right (normal) SVC.

The exam is otherwise unremarkable.

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Case 44

Malignancy / Age 31-60, Atelectasis (Lobar), Juxtaphrenic Peak Sign, Left Upper Lobe Collapse, Post-Obstructive Collapse, Silhouette Sign

This radiograph demonstrates left upper lobe collapse. This is one of the more challenging lobar collapse patterns to recognize on AP or PA radiographs as the left upper lobe collapses anteriorly and superiorly and ends up superimposed over the inflated left lower lobe. Other than the increased opacity over the left hemithorax, other notable features present on this radiograph are a left juxtaphrenic peak sign and silhouetting of the left heart border and hilum by the collapsed left upper lobe.

When this finding is identified, the cause of the collapse should be further investigated with CT. This case was post-obstructive collapse secondary to a central obstructing mass. The mass is not well visualized on this radiograph.

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Case 42

ICU/Surgery, Lines/Tubes/Devices, Malignancy / Age 31-60, Axillary Lymph Node Dissection, Breast Reconstruction, Lymph Node Dissection, Mastectomy, Tissue Expander

This patient underwent bilateral mastectomies for breast cancer. Surgical clips from an axillary lymph node dissection are seen on the right side. The bilateral rounded metallic devices are tissue expanders. They are attached to a radiolucent inflatable bladder that can be progressively filled with saline to stretch the overlying soft tissues, creating redundant tissue that can later be used for reconstruction. The underlying lungs are clear.

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Case 40

Emergency & Trauma, Infectious/Inflammatory / Age 31-60, Pneumonia

This case demonstrates multiple poorly defined opacities in the right lung. In a clinical setting suspicious for infection, this finding is most consistent with multifocal pneumonia as was the case here.

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Case 39

Emergency & Trauma, ICU/Surgery, Mediastinum / Age 31-60, Chest Tube, Clamshell Sternotomy, Lung Transplant, Pneumopericardium, Pneumothorax, Portable

This case demonstrates both a right pneumothorax and pneumopericardium. In this case, the cause was iatrogenic during a bronchoscopy. A right chest tube is in place, though a small apical pneumothorax is still visible.

Clamshell sternotomy closure hardware is also seen, indicating that this is a lung transplant patient.

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Case 33

Malignancy / Age 31-60, Breast Implant, Breast Reconstruction, Mass

This radiograph demonstrates a lobulated mass in the left perihilar region. Also of note is the presence of a unilateral implant in the left breast, suggesting a history of mastectomy and breast reconstruction. Together these findings are highly suggestive of pulmonary metastatic disease from breast cancer. However, tissue diagnosis would be required for confirmation as a primary lung malignancy and metastatic disease from a different, unknown primary are also possible.

The exam is otherwise unremarkable.

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Case 32

Infectious/Inflammatory / Age 31-60, Pneumonia, Silhouette Sign

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 / Age 31-60, Calcification, Granulomatous Disease, Histoplasmosis, Nodule

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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