Age 31-60 – ChestDB.com

Case 33

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

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, Histoplasmosis, Nodule

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 30

ICU/Surgery, Lines/Tubes/Devices / Age 31-60, IABP, Intra-Aortic Balloon Pump, Malposition, Peripherally Inserted Central Catheter, PICC, Portable, Pulmonary Edema, Swan-Ganz Catheter

This radiograph demonstrates a misplaced right IJ Swan-Ganz catheter. Not only is the catheter too deep in the right pulmonary artery, the course of the catheter extends all the way into the abdominal IVC before looping back into the right atrium and crossing the tricuspid valve. Other lines and devices include a left upper extremity PICC with the tip terminating in the SVC, and an intra-aortic balloon pump (IABP) with the distal marker appropriately located just inferior to the aortic knob.

The cardiac silhouette is prominent and there is mild interstitial edema, which makes sense in the context of an IABP indicating that the patient is in heart failure.

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Case 28

Chronic & ILD / Age 31-60, Albers-Schönberg Disease, Fracture, Marble Bone Disease, Osteopetrosis, Portable

This radiograph demonstrates osteopetrosis (also known as marble bone disease and Albers-Schönberg disease), a disorder of osteoclasts which leads to unopposed osteoblastic activity. The bones are diffusely thickened and sclerotic. Multiple rib fractures are noted, highlighting the fragility of the disorganized bone.

The lungs and mediastinum are unremarkable.

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Case 26

ICU/Surgery, Lines/Tubes/Devices / Age 31-60, Portable, Pulmonary Edema, Tracheostomy Mask, Tracheostomy Tube

This radiograph demonstrates unilateral pulmonary edema in the right lung. The differential for this appearance is limited and includes severe mitral regurgitation (such as a papillary muscle rupture), unilateral pulmonary venous obstruction, and lymphangitic spread of malignancy mimicking edema. Those etiologies rarely present with as much uniformity as this case, which was due to prolonged decubitus positioning that rapidly resolved on subsequent radiographs.

Incidentally noted is the presence of a tracheostomy tube with an overlying tracheostomy mask supplying oxygen to the patient.

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Case 24

Lines/Tubes/Devices, Normal & Variants / Age 31-60, Peripherally Inserted Central Catheter, Persistent Left SVC, PICC

This radiograph demonstrates a left upper extremity peripherally inserted central catheter (PICC) with tip terminating in a persistent left SVC. The presence of a persistent left SVC was confirmed on review of prior cross sectional imaging. A PICC in the internal thoracic vein can have a similar appearance on AP/PA radiographs, however a lateral radiograph easily distinguishes the two as a persistent left SVC will course centrally and the internal thoracic vein will course anteriorly.

The radiograph is otherwise unremarkable.

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Case 22

Malignancy / Age 31-60, Kerley B Lines, Lymphadenopathy, Lymphangitic Carcinomatosis, Lymphangitic Spread of Malignancy, Metastatic Disease, Paratracheal Stripe Thickening

This patient presented with a mass at the base of his right neck which is evident on this radiograph. There is a unilateral increase in interstitial markings seen only in the right lung. Kerley B lines are also seen in the right lung base, but there is little other evidence to suggest pulmonary edema or fluid overload. Other pertinent findings include thickening of the right paratracheal stripe and an asymmetrically prominent right hilum.

This constellation of findings is concerning for malignancy causing venous and lymphatic obstruction as well as lymphangitic spread of malignancy and should prompt further evaluation with CT. In this case, the neck mass, thickening of the paratracheal stripe, and the prominent right hilum all corresponded to lymphadenopathy on CT and there was nodular interlobular septal thickening, confirming lymphangitic carcinomatosis. Further investigation in the abdomen revealed a large renal mass as the likely primary malignancy.

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Case 20

Chronic & ILD / Age 31-60, Bronchiectasis, Cystic Fibrosis, Port

This radiograph demonstrates severe cylindrical bronchiectasis, also referred to as tubular bronchiectasis, in an adult patient with cystic fibrosis. This patient has symmetric upper lobe disease which is a common pattern in this condition, though other distributions are not uncommon.

An implanted port is also seen with the tip terminating in the superior vena cava. The port reservoir is placed in the inferior chest wall in this patient, which is an unusual location.

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Case 17

Infectious/Inflammatory / Age 31-60, Consolidation, Parapneumonic Effusion, Pleural Effusion

This radiograph demonstrates patchy mixed ground-glass and consolidative airspace opacities in the left lung with an associated moderate pleural effusion. In this patient with a cough and a white count, this appearance is consistent with pneumonia with parapneumonic effusion.

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