This document provides an overview of pediatric chest x-ray cases from the month. It discusses several cases including a child who swallowed magnets, a case of complex left lower lobe pneumonia evaluated with chest x-ray, CT, and ultrasound, a case of right middle lobe pneumonia in a child found to have a low hemoglobin, and finally a series of cases demonstrating the chest wall deformity pectus excavatum.

1. Pediatric Chest X-Rays Of The Month
Nikki Richardson MD & Jennifer Potter MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
January 2019

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC departments, and now… Tanzania and Brazil.
 Cases submitted this week will be distributed monthly.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. The majority of the cases this month show a step-wise approach to final
diagnosis using multiple imaging modalities.

5. Normal CXR
for your reference

6. HPI: 7-year-old female was
attempting to oppose small
magnets on either side of
her teeth when she
accidentally swallowed
them.

7. HPI: 7-year-old female
presents to the ED after
her mother witnessed her
swallow something while
playing with a toy.
Two adjacent, a round, metallic
density objects project over the
region of the body of the
stomach.
Dx: Ingested foreign body.

8. HPI: On further discussion,
that 7-year-old admits to
attempting to oppose two
magnets on her teeth and
accidentally swallowed the
magnets. Poison control
called and they
recommended repeat film
1 hour after initial to
evaluate for movement.

9. HPI: On further discussion,
that 7-year-old admits to
attempting to oppose two
magnets on her teeth and
accidentally swallowed the
magnets. Poison control
called and they
recommended repeat film
1 hour after initial to
evaluate for movement.
Progression of magnets to
midline (approx. level of L3).
Dx: Ingested magnets.

10. HPI: Patient transferred to
hospital with pediatric GI
specialist for endoscopic
removal of magnets. No
magnets visualized on
endoscopy. PACU XR
obtained post procedure.

11. HPI: Patient transferred to
hospital with pediatric GI
specialist for endoscopic
removal of magnets. No
magnets visualized on
endoscopy. PACU XR
obtained post procedure.
Progression of magnets to distal
small bowel vs descending colon.

12. HPI: Patient sent home
after initial removal
attempt with strainer for
stool. Did not pass
magnets and returned to
GI specialist 3 days later.
Progression of magnets to
midline pelvis.
Successful removal in
endoscopy suite.

13. HPI: 4 year old female with
no past medical history
presents to the ED for
evaluation of fever, pain at
his belly button and cough
for the last 10 days. CT
abdomen obtained to rule
out appendicitis.

14. HPI: 4 year old female with
no past medical history
presents to the ED for
evaluation of fever, pain at
his belly button and cough
for the last 10 days. CT
abdomen obtained to rule
out appendicitis.
Dx: Complex Left Lower Lobe
Pneumonia.
Airless left lower lung.
Left pleural effusion.

15. Given findings on CT
abdomen/pelvis, a CXR was
obtained.

16. Given findings on CT
abdomen/pelvis, CXR was
obtained.
Dx: Complex Left Lower Lobe
Pneumonia.
Opacification of left lower lobe.
Left pleural effusion.

17. Let’s add one final imaging
modality of this
patient…Ultrasound!

18. Lets add one final imaging
modality of this
patient…Ultrasound!
Dx: Empyema requiring VATS
procedure.
Echogenic fluid in lung base.
Septations.
Spine sign.
Thank you to Dr. Denise Fraga for her assistance in the interpretation of this thoracic US!

19. Spine Sign on Thoracic Ultrasound
• Hyperechoic line of vertebral
bodies seen above the
diaphragm on thoracic
ultrasound.
• Suggests presence of a clinically
relevant pleural fluid collection.
Dickman, E., Terentiev, V., Likourezos, A., Derman, A. and Haines, L., 2015. Extension of
the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion. Journal of
Ultrasound in Medicine, 34(9), pp.1555-1561.

20. HPI: 5-year-old female
presents for fever, chills
and nonproductive cough
for 5 days. Found to have a
hemoglobin of 2.6.

21. HPI: 5-year-old female
presents for fever, chills
and nonproductive cough
for 5 days. Found to have a
hemoglobin of 2.6
Dx: Right Middle Lobe
Pneumonia.
Patchy opacity.

22. CT angiography of the
chest obtained to further
evaluate.

23. CT angiography of the
chest obtained to further
evaluate.
Ddx: Diffuse pulmonary
hemorrhage; pulmonary
vasculitis; bilateral pneumonia.
Bilateral patchy ground glass
opacities.
Consolidation
VATS lung biopsy performed;
results pending.

24. HPI: 5-year-old with
muscular dystrophy
presents with 2 days of flu-
like symptoms
Dx: Multifocal Pneumonia
Patchy opacities

25. Bacterial Pneumonia and Influenza
• In a study by Williams et al of over 3,000 children with complicated
pneumonia:
• In patients with complicated pneumonia AND influenza the most common
bacterial pathogens were:
• 22.9% Staphylococcus aureus
• 66.7% of S aureus was Methicillin- resistant S aureus
• 20.0% Streptococcus pneumoniae
• If concerned for influenza co-infection or post-influenza bacterial
pneumonia add VANCOMYCIN to your antibiotic regimen.
• For more about influenza, visit Emergency Medicine Guidewire’s
podcast on Pediatric Influenza
Williams DJ, Hall M, Brogan TV, et al. Influenza Coinfection and Outcomes in Children With Complicated
Pneumonia. Arch Pediatr Adolesc Med. 2011;165(6):506–512.
https://www.aafp.org/afp/2012/1001/p661.html

26. What’s with these kids?
For the next section, we will review a series of cases/images with a
unifying diagnosis. Try to identify the similarities and come up with the
diagnosis! After each series of cases, we will discuss the
pathophysiology and imaging characteristics of the diagnosis.
These images and cases have been graciously shared with us from our
collogues in the pediatric cardiovascular surgery department. We thank
you for your continued support of this project!

27. For this diagnosis, no HPI or
physical exam findings will
be provided.
Good luck!

28. A

29. B

30. C

31. Chest CTs of all 3 cases

32. So, what’s with these kids??

33. Pectus Excavatum (PE)
• Most common congenital chest
wall deformity
• Occurs in 1 in 400 to 1 in 1000 live
births per year
• Male predominance as high as 9:1
• Specific genetic defect is not
known however family history
present in 43% of cases
• Most are isolated; but can be
associated with other clinical
conditions
https://emedicine.medscape.com/article/1004953-overview
Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14, 2012,
pp. 801–806., doi:10.1093/icvts/ivs045.
Rhee, Diane, et al. “Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With Marfan Syndrome.” Archives of Pediatrics & Adolescent
Medicine, vol. 162, no. 9, 2008, p. 882., doi:10.1001/archpedi.162.9.882.

34. Pectus Excavatum: Associated conditions
• Connective tissue disorder (< 1%)
• Marfan Syndrome
• Ehlers-Danlos Syndrome
• Noonan Syndrome
• Poland Syndrome
• Neurofibromatosis Type I
• Homocystinuria
• Fetal Alcohol Syndrome
• Osteogenesis imperfecta
• Socio-psychological problems;
especially in adolescents
https://step2.medbullets.com/orthopedics/120522/marfan-syndrome
https://radiopaedia.org/articles/pectus-excavatum?lang=us
Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive
Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045.

35. Pectus Excavatum: Physiology Considerations
• Reduced heart and lung volume
• Mitral valve prolapse or
regurgitation
• Ventricular compression
https://www.stanfordchildrens.org/en/service/chest-wall/pectus-excavatum
Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive
Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045.

36. Pectus Excavatum: Clinical Presentation
• History
• Chest pain
• Dyspnea on exertion
• Multiple respiratory infections
• Asthma-like symptoms
• Decreased exercise tolerance
• Easy fatigability
• Anxiety/depression associated
with deformity
• OR patient can be asymptomatic
• Physical Exam
• Sunken chest wall; may be midline
or asymmetrical
• Thin
• Tall
• Pot-bellied
• Forward hunched shoulders
• May have holosystolic murmur at
the apex
Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14,
2012, pp. 801–806., doi:10.1093/icvts/ivs045.
Wu, Peter C, et al. “Repair of Pectus Excavatum Deformities in Children: A New Perspective of Treatment Using Minimal Access Surgical Technique .” Arch
Surg, vol. 136, 2001, pp. 419–424.

37. Pectus Excavatum: Evaluation In The ED
• Likely to be a physical exam finding in a
child presenting to the ED for
unrelated complaint
• If presenting with cardiac or
pulmonary complaints consider
obtaining:
• POC Cardiac US
• Aortic root dilatation is more common in
pectus excavatum
• If both pectus excavatum AND aortic root
dilatation; may require genetics testing
• Mitral valve dysfunction
• CXR to evaluate for infectious etiology
given propensity for pneumonia
Rhee, Diane, et al. “Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With
Marfan Syndrome.” Archives of Pediatrics &amp; Adolescent Medicine, vol. 162, no. 9, 2008, p. 882.,
doi:10.1001/archpedi.162.9.882.

38. Pectus Excavatum: CXR findings
1. Poorly defined right heart border
on AP
2. Widening of the cardiac
silhouette due to compression
seen on lateral
3. Leftward displacement of the
cardiac silhouette
4. Horizontal orientation of
posterior ribs
5. Vertical orientation of anterior
ribs
1 2
34
5
https://radiopaedia.org/articles/pectus-excavatum?lang=us

39. Pectus Excavatum: CXR findings
1. Poorly defined right heart border
on AP
2. Widening of the cardiac
silhouette due to compression
seen on lateral
3. Leftward displacement of the
cardiac silhouette
4. Horizontal orientation of
posterior ribs
5. Vertical orientation of anterior
ribs
1 2
34
5
https://radiopaedia.org/articles/pectus-excavatum?lang=us

40. Pectus Excavatum: Operative Repairs
• Ravitch-type Repair:
• Open
• Cartilage resection and sternal osteotomy
• Internal bracing (Robicsek suspension)
• Gold standard
• Avoided in young children secondary to
potential for restrictive lung disease after
repair
• Nuss Procedure:
• Minimally invasive
• No cartilage resection
• Transthoracic retrosternal stainless steel
bars placed for 2-4 years
• More commonly complicated by
pneumothorax
Wu, Peter C, et al. “Repair of Pectus Excavatum Deformities in Children: A New
Perspective of Treatment Using Minimal Access Surgical Technique .” Arch Surg,
vol. 136, 2001, pp. 419–424.
Photo from Pediatric Cardiovascular Surgery Department at
Levine’s Children’s Hospital

41. Pectus Excavatum: Non-Operative Repair
• Vacuum Bell:
• Non-operative option
• Factors that have shown higher
success rates
• Mild form of pectus excavatum
• Symmetric
• Greater chest wall compliance
• No costal flaring
• Permanence of this technique still
not fully known
Photo from Pediatric Cardiovascular Surgery
Department at Levine’s Children’s Hospital
Patel, Akshay J, and Ian Hunt. “Is Vacuum Bell Therapy Effective in the Correction of
Pectus Excavatum?” Interactive CardioVascular and Thoracic Surgery, vol. 29, no. 2,
2019, pp. 287–290., doi:10.1093/icvts/ivz082.

42. Pectus Excavatum: Post-Operative CXRs
Ravitch-type Repair with Robicsek mesh
suspension
Nuss Procedure

43. Summary Of This Month’s Diagnoses
• Swallowed Magnets
• Complex Left Lower Lobe
Pneumonia
• Empyema (Ultrasound)
• Right Middle Lobe Pneumonia
• Pulmonary Hemorrhage
• Multifocal Pneumonia +
Influenza
• Pectus excavatum