Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: March Cases

Pediatric Chest X-Rays of the Month
Elizabeth Olson, MD & Kendra Jackson, MD
Department of Emergency Medicine &
Department of Pediatrics
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD & Mary Grady, MD, Junior Faculty Editors
Chest X-Ray Mastery Project
March 2021

Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments, and now…
Tanzania and Brazil.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
EMGuidewire.com

2-year-old with history of sickle cell anemia
presents with fever, pain all over, and fussiness
CXR interpretation?
Review

2-year-old with history of sickle cell anemia
presents with fever, pain all over, and fussiness
Right upper and lower lobe pneumonia –
Consider acute chest syndrome
Review

20-month-old female presents with
3 days of cough and congestion.
Diagnosed with bilateral otitis
media at PCP one day prior to
arrival. Now with increased work of
breathing and hypoxia.
Interpret this CXR.

What is the circled abnormality?

Diagnosis: Pneumothorax

Because the pneumothorax is
relatively small, the team opts to
treat her with high flow nasal
cannula and serial CXRs instead of
a chest tube. This is her next CXR.
Interpret this CXR.

What abnormality is highlighted by
the arrows? Is there still a
pneumothorax?

The pneumothorax is no longer
radiographically apparent, but a
right perihilar density is now seen.
With antibiotics started, she
improves over the next two days
and is discharged home.

Your colleague calls you over and
asks your opinion of this image
without any background
information.
Interpret this CXR.

Your colleague calls you over and
asks your opinion of this image
without any background
information.
What is the circled abnormality?

Interpretation: RLL infiltrate.
Additional information: Patient is a
16-year-old boy who moved to the
US from Guatemala 2 years ago. He
presents with 3 days of fevers and
hemoptysis.
He is diagnosed with RLL
pneumonia and discharged on
antibiotics. He returns 3 days later
with worsening symptoms. See
next slide for repeat CXR.

Repeat 3 days later Original
Despite antibiotics, his fevers
continue, and his hemoptysis
is worsening. He is admitted
for IV antibiotics, having
failed outpatient
management.
With worsening hemoptysis,
a history of travel outside of
the US, and an infiltrate that
has become denser despite
antibiotics, what additional
testing should you send?

Tuberculosis
Consider in patients with international travel history,
working/living in a nursing home or detention facility,
or with a positive close contact.
- Usually has a more indolent, subacute
presentation. This patient is atypical, having only
had symptoms for a few days.
- QuantiFERON gold testing (interferon-gamma
release assay, or IGRA) alone is not sufficient to
confirm or rule out TB.
- Send expectorated sputum samples for AFB (acid
fast bacilli) and NAA (nucleic acid amplification).
Three samples should be sent 8 hours apart.
- Both tests depend on the patient’s ability to bring
up sputum with a sufficiently high organism
burden. Too few mycobacteria can lead to false
negatives.
- Involve your Infectious Disease colleagues. They
will be grateful to talk about something other than
COVID.
U.S. Department of Health & Human Services, Centers for Disease Control, Division of Tuberculosis
Elimination. "Report of an Expert Consultation on the Uses of Nucleic Acid Amplification Tests for
the Diagnosis of Tuberculosis." Sept 2012.

8-year-old nonverbal child
history of cerebral palsy,
trach dependence
presents with abdominal
distention and hypoxia.
Interpret this CXR.

trach dependence
distention and hypoxia
What is the circled
abnormality?

trach dependence
distention and hypoxia
Radiologist’s interpretation:
Low lung volumes with suspected
bibasilar atelectasis, not well assessed.
Marked gaseous distension of the
bowel causing elevation of the right
hemidiaphragm with a paucity of rectal
bowel gas.
Final diagnosis: Small bowel
obstruction.

16-year-old with cerebral palsy,
nonverbal, presents with abdominal
distention and “pain” per parents.
Recently had multiple abdominal
surgeries for a perforated ulcer.
Interpret this CXR.
Baseline
Current

Radiologist interpretation:
Free intraabdominal air on right
side, compatible with perforated
viscus.
Large gas-containing structure in
left upper quadrant may be
stomach, but is favored to be an
abscess until proven otherwise,
given recent history of gastric
perforation and presence of
intraabdominal free air.

This is a left lateral decubitus
view, i.e., the left side is facing
down.
Note the increased visibility of
the free air at the top of the
image.

From the operative note:
We performed careful and meticulous lysis of adhesions to gain access to the LUQ. We
were concerned that the structure thought to be a dilated stomach may be a large
abscess cavity. We discovered this to be true as we entered the capsule of the abscess
cavity with malodorous air and purulent fluid. We performed an EGD to ensure there
were no injuries to the stomach. The esophagus, stomach, and duo were intact with
no signs of injury. We performed a bubble test and found no evidence of leak. We
excised as much of the abscess wall cavity as possible--it was thick and adherent to
surrounding tissue. It was necessary to leave a significant amount behind.
The VP shunt was found to terminate in the area of the abscess, and this was
externalized by neurosurgery.

Pneumoperitoneum
Upright CXR is the most sensitive plain film
for this pathology.
As little as 1 mL of free air can be seen on
an upright CXR.
A cross-table left lateral decubitus film can
detect 5-10 mL of free air.
For best results, if possible, have the
patient stay in that position for 10-15
minutes before obtaining the xray, to allow
the air to migrate upwards.
Massive pneumoperitoneum in the infant
population can take on the appearance of a
football…if you use a lot of imagination.
Get your surgical colleagues involved in
these cases.
Lee HJ. Plain abdominal radiography in infants and children.
Korean J Paediatr Gastroenterol Nutr. 2011;14:130–6

9-year-old with asthma
and obesity presents with
cough and fever.
Interpret this CXR.

cough and fever.
Radiologist interpretation: Hazy
asymmetric right lung infiltrates.
Differential includes pneumonia,
viral process.
Bonus question: Identify the
dense linear structure.

cough and fever.
Radiologist interpretation: Hazy
asymmetric right lung infiltrates.
Differential includes pneumonia,
viral process.
The indicated structure is the
flexible metal strip from a
surgical mask, worn upside-
down.

Interpret this CXR from hospital
day 2.
9-year-old with asthma and
obesity presents with cough
and fever.
He is discharged home on
antibiotics for CAP. Tests
positive for COVID.
Clinically worsens and is
admitted to the PICU on NiPPV.

“Extensive pneumomediastinum
and subcutaneous emphysema.
Increasing opacities in right
lung. Possible right apical
pneumothorax.”
and fever.
positive for COVID.

Note the striated appearance of
the subcutaneous emphysema
lateral to the right chest wall.
This appearance is caused by air
tracking through the pectoralis
muscles.
and fever.
positive for COVID.

Interpret this abdominal xray.
and fever.
positive for COVID.
His abdomen is becoming
increasingly distended.

Massive pneumoperitoneum.
and fever.
positive for COVID.
His abdomen is becoming
increasingly distended.

What intervention was
performed by surgery?
The patient continued to
decline, is intubated, and
ultimately is placed on ECMO.
As the patient’s distended
abdomen was by this point
impeding his lung compliance
and causing decreasing tidal
volumes, surgery was
consulted.

Surgery placed a peritoneal drain.
From their operative report:
“ECMO team reports progressive
decreasing flows on ECMO. …
Decision made to emergently
place pigtail drain in peritoneal
cavity to decompress abdomen.
... Needle inserted to the left of
and just above umbilicus with
gush of air as needle entered
peritoneal cavity. A 15 cm 8.5
French pigtail was placed. During
procedure, ECMO specialist
reported flows immediately
improved.”

Despite aggressive
intervention, the patient
continues to decline. Here is a
follow-up CXR.
1) Identify the lines/support
structures in this image.
2) What new abnormality is
seen in the lung fields?

Despite aggressive
follow-up CXR.
1) Identify the lines/support
structures in this image.
2) What new abnormality is
seen in the lung fields?
A
B
C
E
D

A
B
C
E
D
Despite aggressive
follow-up CXR.
A) ECMO cannula
B) ECMO cannula
C) Endotracheal tube
D) NG or OG tube
E) New left pleural effusion

7-year-old with history of severe scoliosis
develops hypoxia while admitted for
pyelonephritis.
Identify the abnormalities.
Baseline
Current

pyelonephritis.
What are the indicated abnormalities?
Baseline
Current

pyelonephritis.
Diagnosis: Large left pleural effusion and
small right pleural effusion, likely due to
volume overload from aggressive fluid
resuscitation. There are air bronchograms
evident in the left lung field.
Baseline
Current

Interpret this CXR.
15-year-old presents with fever
and hemoptysis for two days.
Three weeks ago, she was
diagnosed with type 1 diabetes
after presenting in new-onset
DKA, and incidentally tested
positive for COVID, but was not
symptomatic at that time.

Thick walled cavitary lesion in
the right upper lobe measuring
approximately 6cm with
adjacent right upper lobe
consolidation.
15-year-old presents with fever
and hemoptysis for two days.
Three weeks ago, she was
diagnosed with type 1 diabetes
after presenting in new-onset
DKA, and incidentally tested
positive for COVID, but was not
symptomatic at that time.

CT angiography was ordered to
evaluate the extent of the cavitary
lesions. No specific culprit vessel was
found that could be blamed for the
hemoptysis.

Extensive workup was largely unrevealing.
- Tuberculosis testing was negative (negative AFB, negative NAA, negative
QuantiFERON)
- Auto-immune testing was negative (ANCA, anti-myeloperoxidase, anti-
proteinase-3 antibodies)
- Fungal testing was negative (aspergillus galactomannan, histoplasma
antigen)
- Viral pathogen panel negative
Sputum cultures did grow MSSA, for which she was treated with
improvement.
She was discharged with plan to follow up with rheumatology as well as
obtain cystic fibrosis testing as an outpatient, given poor weight gain, new
diagnoses of diabetes and Celiac disease, and unusual lung pathology. If
this is negative, then the likely culprit is post-COVID MSSA pneumonia. This
is unusual, as she had no respiratory symptoms while infected with COVID.

Summary of This
Month’s Diagnoses
• Acute chest syndrome (review)
• Pneumothorax & Pneumonia
• Tuberculosis
• Small bowel obstruction
• Intraabdominal abscess with free air
• COVID
• Subcutaneous emphysema &
Pneumomediastinum
• Pneumoperitoneum
• ECMO & Pleural effusion
• Pleural effusion
• Cavitary lung lesions from MSSA
EMGuidewire.com

Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: March Cases

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