POSITION PA AP QUALITY ROTATION PENETRATION INSPIRATION LESION HomoDensityinfiltratio Heterogenous Centralperiph Silhouet n Wellill defined Zone eral Necrotic sign MEDIASTINAL Central deviasionwided COSTO-PHRENIC ANGEL Freeoblitern OTHER Bone soft tissuediaphragm
Abscess1. Cavitating infective consolidation.2. Single or multiple lesions.3. organisms. 1. Bacterial (Staphylococcus aureus, Klebsiella, Proteus, Pseudomonas, TB and anaerobes). 2. fungal pathogens are the most common causative4. ‘Primary’ lung abscess – large solitary abscess without underlying lung disease is usually due to anaerobic bacteria.5. Associated with aspiration and/or impaired local or systemic immune response (elderly, epileptics, diabetics, alcoholics and the immunosuppressed)
Radiological features• Most commonly occur in the apicoposterior aspect of the upper lobes or the apical segment of the lower lobe.• CXR may be normal in the first 72 h.• CXR – a cavitating essentially spherical area of consolidation usually>2 cm in diameter, but can measure up to 12 cm.• There is usually an air-fluid level present.
Differential diagnosis• Bronchopleural fistula – direct communication with bronchial tree. Enhancing split pleural layers on CT.• Empyema - enhancing split pleural layers, forming obtuse margins with the lung on CT.• Primary or secondary lung neoplasms (e.g. squamous cell carcinomas) • these lesions can run a slow indolent course. • Failure to respond to antibiotic therapy should alert the clinician to the diagnosis.• TB (usually reactivation) – again suspected following slow response to treatment.
Case-1• This was a 48-year-old male with fever of one week’s duration.• He was extremely ill and hypotensive requiring inotrope therapy.
POSITION •AP CXRQUALITY •Poor Technical Quality •Bilateral patchy ill defined nodules •Diffused but Most in middle ,lowerLESION zone . •Peripheral region. •Central trachea and mediasteinal?MEDIASTINAL •Hazy costo-phrenic angels.ANGELS •NOOTHER
discussion• This patient actually has Klebsiella bacteremia.• In parts of South-East Asia, Burkolderia pseudomallei may result in the same CXR appearance.• The other important etiologic agent is Staphylococcus aureus bacteremia.
Case-2• This patient presented with cough and fever of one month’s duration.• She is a known case of COPD with a past history of surgery to the left lung.
POSITION •PA CXRQUALITY •Poor Technical Quality •(PENETRATION) •WELL defined necrotic round density (cavitary) .LESION •In middle zone at right hilum (apical •Hazy density at right lower zone RLL) (bronchogram) •Central trachea and mediasteinal?MEDIASTINAL •FREE costo-phrenic angels.ANGELS •Fracture at posterior 4-5 ribs.OTHER
discussion• The causes of lung cavities include : – primary lung cancer (typically Squamous cell) – tuberculosis. – Klebsiella. – Staphylococcus aureus (usually multiple). – Anaerobes. – Mycetoma. – Wegener’s granulomatosis. – rheumatoid nodule. – and pulmonary infarction.• Lesions in the upper lobe and apical segment of the lower lobes are typical of pulmonary tuberculosis.
Case-3• A young male with acute myeloid leukemia underwent a bone marrow transplant.• This was complicated by relapse of the leukemia and persistent neutropenic fever.• A CXR two months ago was normal
POSITION •AP CXR •Poor Technical QualityQUALITY •(PENETRATION,ROTATION?) •Triangular homogenous density,it,s base at chest wall (bronchogram),otherLESION well defined nodule at right upper zone, ill defined nodule at left upper zone. •Hazy density at left lower zone obscured left heart border.MEDIASTINAL •Central trachea and mediasteinal?ANGELS •FREE costo-phrenic angels. •NoOTHER
discussion• The CXR shows a right upper lobe mass, which is wedge shaped with the apex towards the hilum. This shadow is suggestive of a pulmonary infarct.• In addition, the left upper lobe shows a small nodule at the periphery.• The fact that CXR recently was normal makes a severe overwhelming infection very likely.• The CT demonstrated two additional findings. The right upper lobe mass has a necrotic center and a surrounding halo.• This is the classic “halo sign” (ground glass change adjacent to central dense consolidation) around the right upper lobe mass.• The halo is thought to represent edema or hemorrhage due to infection by angiotrophic organisms, the most common being Aspe.rgillus fumigatus
Case-4• patient was admitted for severe acute pancreatitis.• A few days into the admission, the patient became very tachypneic and required intubation and mechanical ventilation.
POSITION •AP CXR •Poor Technical QualityQUALITY •(PENETRATION,ROTATION?) •Bilateral hazy opacites at lower zone ,perihilar ill defined nodule?(bronchogram?)LESION •May obscured right hemidiaphragm •No kerly B line no cardiomegaly.MEDIASTINAL •Central trachea and mediasteinal?ANGELS •Hazy left costo-phrenic angels. •NoOTHER
discussion• These are features of ARDS.• The common causes of ARDS include: – septic conditions like severe pneumonia, – multiple fractures, – massive blood – transfusion, – near drowning, – and pancreatitis.
CASE-5• An 80-year-old male presented with massive hemoptysis and was intubated.• He gave a past history of being treated for tuberculosis many years ago.
POSITION •AP CXR •Poor Technical QualityQUALITY •(PENETRATION,ROTATION?) •Cavitation opacity . •At right upper zone extend to apex.LESION •Ball density inside it, and gas crescent above it.MEDIASTINAL •Central trachea and mediasteinal?ANGELS •Free costo-phrenic angels. •NoOTHER
Discussion• The CXR shows a right upper lobe ball within a cavity (air crescent sign) pathogmonic of a mycetoma (also called aspergilloma).• A lateral decubitus X-ray may demonstrate the fungal ball shifting position.• In this condition, a preformed cavity becomes colonized, usually by the fungus Aspergillus fumigatus.• Cavitary disease may be secondary to: – fibrotic lung disease, e.g: • . previous tuberculosis, • sarcoidosis, • ankylosing spondylitis.• Massive hemoptysis can result and bronchial angiogram with embolotherapy (using coils or gel foam) is temporizing.