Age 31-60

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 30

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , ,

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 / , , , , ,

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 / , , , ,

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 / , , ,

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 / , , , , ,

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 vascular 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 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. Further investigation in the abdomen revealed a large renal mass as the likely primary malignancy.

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Case 20

Chronic & ILD / , , ,

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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