Imaging in ailments of paediatric chest

1. PAEDIATRIC CHEST
Dr Kamal Adhikari
Resident, MD Radiodiagnosis
NAMS

2. Imaging techniques
• Plain radiograph
• Barium swallow
• Fluoroscopy
• Computed Tomography
• MRI
• Ultrasonography
• Radionuclide imaging
• Bronchography/Angiography

3. Chest X-ray
• Basic investigation in childhood chest pathologies.
• Adequate inspiration – Right hemidiaphragm at the level of 8th rib
posteriorly.
• Expiration –
 Kink of trachea to right side.
 varying degree of opacification of lung fields.
Abnormal enlargement of heart.
• Differentiation between PA and AP film difficult.
• Difficulties in imaging – motion artefact and insufficient inspiration

4. • Need to consider some specific features in children:
Thymus
CTR – exceed usual 50%
Kink of trachea to right – If < full inspiration, tracheal kink to right.
Soft tissues – prominent in children e.g. anterior axillary fold crossing chest
wall can mimic pneumothorax.
 Plaits of hair over upper chest mimic infiltrations.
Pleural effusions – Seen as separation of lung from chest wall with relative
preservation of CP angle and accentuation of lung fissures.

5. Thymus
• Normal thymus in children – widened mediastinum.
• Lateral margin shows undulation – thymic wave.
• Towrads right, normal thymus may show triangular “sail-like”
configuration.
• Decreased size at stress and with steroids.
• Pathology identification can be difficult.
• USG helps – cystic lesions from homogenous normal thymus.
• MRI: Normal thymus homogenous SI while pathologies –
heterogenous.

7. • Fluoroscopy: Need to limit radiation exposure, pulsed rather than
continuous.
• Evaluation of differing radiolucencies in suspected foreign bodies.
• Obstructive emphysema: affected lung shows little volume change with
respiration, mediastinum shifts contralaterally on expiration.
• Lateral fluoroscopy: for dynamic evaluation of tracheomalacia.
• Barium swallow: Vascular rings, extrinsic masses, laryngeal clefts and
TOF.
• Either single contrast barium or water soluble contrast studies.

8. MRI
• Cardiac gated MR and MRA, assessment of cardiac lesions, great
vessels, mediastinal masses, tracheobronchial anomalies and
neurogenic masses.

9. Ultrasonography:
• Obviates the need for radiation.
• Evaluation of pleural fluid, pleural masses, peri diaphragmatic masses
and neck masses, pericardial disease, diaphragmatic pathologies,
evaluation of thymus.
• Antenatal ultrasonography – can identify the congenital pathologies
like sequestration.

10. • Bronchography:
• HRCT (thin sections) almost eliminated bronchography in children.
• Still used for functional bronchography and dynamics of
tracheobronchomalacia.
• Angiography:
• Therapeutic in bronchial artery embolization.
• In severe hemorrhage/ Hemoptysis in cystic fibrosis.

11. CT Scan
• Problems –
Cardiac and respiratory motion artefact.
 Less good tissue contrast due to paucity of mediastinal fat.
Ultrafast electron beam CT , Spiral CT and volumetric CT used – reduce
scan time  reduce need for sedation.
• HRCT –
Diffuse lung disease assessment.
Opportunistic lung disease assessment.
Road map for minimal invasive thoracic procedures.

12. Tracheobronchial abnormalities
Tracheal agenesis:
• Rare.
• Maternal polyhydramnios.
• Respiratory distress, absent cry and cannot intubate.
• 3 types:
Type I: No upper trachea, lower trachea Oesophagus
Type II: No trachea, common bronchus Oesophagus
Type III: Separate bronchi, separately connected to oesophagus.

13. Tracheal stenosis
• Acquired or congenital (rare).
• Following prolonged intubation or traumatic suctioning.
• Congenital stenosis d/t complete cartilaginous ring.
• Focal/generalized/funnel shaped.
• Funnel shaped d/t pulmonary artery sling.
• Presentation: 1st year of life with biphasic stridor.
• Bronchoscopy, CT, MRI.
• Associated anomalies: Tracheo-esophageal fistula, pulmonary
agenesis or hypoplasia, pulmonary artery sling and bronchial stenosis.

14. Tracheal stenosis. A, Axial CT shows severe narrowing of the
trachea at the level of thoracic inlet (arrow) approximately 7
cm from the glottis. B, Coronal MiniP image shows severe
narrowing (arrow) at the level of thoracic inlet.

15. Tracheomalacia
• Expiratory collapse of trachea due to softening of tracheal wall.
• Secondary to: Cartilagenous anomalies.
Tracheostomy.
Oesophageal atresia or TOF.
Chronic inflammation (cystic fibrosis, recurrent aspiration,
immunodeficiency).
Extrinsic compression (vascular rings, slings or aberrancy).
Neoplasia.

16. • Expiratory wheeze,
exacerbated with crying,
normal at rest.
• Lateral fluoroscopy:
Exaggerated decrease in
sagittal width of trachea
during expiration.
• Dynamic CT: assess cross
sectional anatomy and
compliance of trachea.
Tracheomalacia. Radiograph of the trachea in a 2-month-old
infant with stridor shows marked diffuse tracheal narrowing
during expiration (arrows). Radiographs of a 3-week-old infant
with Hurler disease

17. Tracheo-oesophageal fistula
• Choking, cyanosis, coughing at feeding, insidiously as chronic
respiratory infection.
• Oesophageal atresia – obvious diagnosis.
• Majority associated with oesophageal atresia.
• If not, diagnosis difficult.
• Contrast oesophagogram: Fine hair-like structure connecting
oesophagus and trachea with linear opacification of posterior
tracheal wall.

18. • Type A - Esophageal atresia without fistula so-called pure esophageal atresia (10%)
• Type B - Esophageal atresia with proximal TEF
• Type C - Esophageal atresia with distal TEF (85%)
• Type D - Esophageal atresia with proximal and distal TEFs
• Type E - TEF without esophageal atresia or so-called H-type fistula (4%)

19. Bronchial atresia
• Upper lobe bronchi frequently atretic.
• Newborn: Mass occupying part or all of an upper lobe (fetal lung fluid
trapped behind the atresia).
• Later, fetal lung fluid escapes via pores of kohn/canals of lambert –
round opacity central to air trapping.
• Associations: Bronchogenic cyst, intralobar sequestration or cystic
adenomatoid malformation.

20. Bronchial atresia. Axial CT shows an area of mucoid plugging in
the left lower lobe (white arrow), and distal to this there is an
area of hyperlucency (black arrow), consistent with bronchial
atresia.

21. Tracheal bronchus
• also known as PIG bronchus.
• 1% of normal population.
• right upper lobe bronchus directly arises from the trachea.

22. Tracheal bronchus. Coronal CT shows the tracheal bronchus
(bronchus suis) (arrow) originating from the trachea and
supplying the right upper lobe.

23. Congenital pulmonary venolobar syndrome
• Scimitar syndrome
• Congenital aplasia or hypoplasia of one or more lobes of right lung.
• Other variable features:
Partial anomalous pulmonary venous return
Anomalous or rudimentary arterial supply of the hypolplastic lobes
(small pulmonary artery or supply directly from thoracic
aorta/abdominal aorta/celiac axis).
Hemidiaphragm abnormality
Small hemithorax, obscuration of heart border, retrosternal soft
tissue density.

24. • AP view: Anomalous vein has “Turkish Scimitar” shape, drains into IVC
or even hepatic vein or portal vein or right atrium.
• May be association with pulmonary sequestration (right lower lobe) –
appears as mass of abnormal lung tissue.

26. Lung Agenesis
• Small opaque hemithorax, ipsilateral
mediastinal shift
• Presentation: Neonatal respiratory
distress. Can even present in
adulthood, radiologically as “White-
out” hemithorax.
• Bronchography/Bronchoscopy:
Absent mainstem bronchus
• Angiography: No pulmonary or
bronchial artery circulation.
• Association: VATER syndrome
• D/D: Pulmonary hypoplasia and
complete lung atelectasis

27. Pulmonary Hypoplasia
• Factors compromising thoracic space available for lung growth.
• Intrathoracic: diaphragmatic hernia or extralobar sequestration
• Extrathoracic: Oligohydramnios/arthrogryphosis
• Classically right lung involved.
• Right sided obstructive heart disease
• Association: Diaphragmatic hernia, renal agenesis/dysgenesis
• Imaging:
• Decrease in volume of right hemithorax.
• I/L mediastinal shift.
• Obscuration of heart border d/t extrapleural areolar tissue.

30. Congenital Lobar Overinflation/emphysema
• Progressive overdistension of a lobe or may be 2 lobes.
• Emphysema – misnomer, no alveolar wall destruction.
• Cause: Ball-valve mechanism obstruction of bronchus
Abnormal bronchial cartilage deficiency/dysplasia
Inflammatory changes Wall abnormality
Inspissated mucus
Mucosal folds/webs Intraluminal
Broncial stenosis
Extrinsic vascular or mass compression Extraluminal cause

31. • M:F = 3:1
• Associated anomalies: Cardiovasular up to 50%, PDA, VSD and TOF
• Lobar involvement: Upper lobes or right middle lobe
• Left upper – 43%, Right middle – 32%, right upper – 20%, lower lobes
– 5%.
• Radiography:
• Neonate: Fluid may get trapped, opaque enlarged hemithorax.
• Later, fluid resorption, grossly overinflated lobe with generalized
hypertransradiancy, marked attenuation of pulmonary vessels,
compression of adjacent lobes.

32. Congenital lobar emphysema/overinflation. Chest X-ray
shows gross overinflation of the right lung which is hypovascular
with marked shift of the mediastinum to the left and herniation of
the lung into the left hemithorax (arrow). (B) CT of right middle
lobe congenital lobar overinflation/emphysema causing shift of
the mediastinum to the left with marked distortion of the pleural
reflections to the left of the midline.
Hyperexpansion of the left upper lobe
with a portion herniated across the
midline. There is shift of the
mediastinum to the right, flattening of
the left hemidiaphragm and some
compression of the left lower lobe.

33. Bronchopulmonary foregut malformations
• Developmental anomalies from abnormal budding of the embryonic
foregut and trachea-bronchial tree.
Foregut cysts
Bronchogenic cysts
Enteric and neurenteric cysts
Cystic hamartomatous adenomatoid malformation
Pulmonary sequestration

34. Bronchogenic cysts
• ½ of all congenital thoracic cysts
• Intrapulmonary or mediastinal (>common, earlier budding
abnormality)
• Lined by ciliated epithelium, may contain smooth muscle and
cartilage
• Mediastinal cysts: paratracheal (right sided >), carinal (m/c) or hilar
• No communication with tracheobronchial tree
• Instrumentation or infection – air-fluid level or air filled cyst.
• D/D – Acquired cyst, cystic mesenchymal hamartoma.

35. CT: Large fluid density lesion in
right superior mediastinum, no
invasion into mediastinum or
lung
Coronal T2-weighted image in the same
patient shows a hyperintense lesion (arrow)
splaying the carina.

36. Enteric cysts
• Early embryogenesis
• Located in posterior mediastinum
• If in oesophageal wall, oesophageal
cysts or duplication cysts.
• Can present early with acid
secretion, may rupture into
tracheobronchial tree leads to
hemoptysis.
• Large posterior mediastinal mass
(right-sided).
• Tc-MDP scan, uptake – gastric
mucosa.
Esophageal duplication cyst in a 3-year-old girl with
cough and dyspnea. (a) Chest radiograph shows
homogenous opacification of the right hemithorax
(arrows) at the time of first admission. (b) Follow-up
CT scan 3 years later shows a large cystic
periesophageal mass (arrows)

37. Neuroenteric cysts
• Posterior mediastinal masses with associated vertebral abnormalities.
• MRI needed to evaluate thoracic or spinal components of these cysts.
• Foregut cysts can have water attenuation or even increased
depending on viscousity of content.
• CT attenuation or MRI intensity varies.
• Usually unilocular and no enhancement.

38. Neurenteric cyst in female patient with flank pain. (a) Chest radiograph shows a well-defined round mass (arrow)
in the lower thoracic region. (b- c) Both axial T1-weighted – and coronal T2-weighted MR images show a large
mass that is of homogenous high signal intensity in the right paravertebral region (arrow). The cyst presumably
contains proteinaceous fluid. (d) The photograph of the resected tumor shows a thick-walled encapsulated cystic
mass.

39. Congenital Cystic Adenomatoid Malformation
• Hamartomatous proliferation of terminal bronchioles at the expense of
alveolar development.
• Lesions composed of both cystic and solid components.
• Cysts communicate with tracheobronchial tree.
• Predilection for upper lobes.
• Type I: m/c, 50%, variable cysts, at least 1 cyst > 2 cm d, < 5% congenital
anomalies.
• Type II: 41%, smaller, uniform cysts < 2 cm, 50% children anomalies (renal,
intestinal, skeletal, cardiac)
• Type III: microcysts, solid in gross, fetal hydrops and polyhydramnios,
associated congenital anomalies, poor prognosis.

40. Modified Stocker CPAM
Type Description
• 0 Incompatible with life
• 1 Commonest type (>65%)
Several large intercommunicating cysts (up to 10 cm)
Mediastinal shift is common
• 2 10–15% of cases
Smaller than other types
Small evenly sized cysts (up to 2 cm)
Often associated with other congenital abnormalities
• 3 ~8% of cases
Large solid lesion with small cysts (1.5 cm)
Nearly always causes mediastinal shift
Poor prognosis
• 4 10–15% of cases
• Large cysts (up to 7 cm) ,May be associated with, or a precursor of pleuropulmonary blastoma

41. Cystic adenomatoid malformation. A, Axial CT shows large
cystic spaces filled partially with fluid in the medial aspect of
the right upper lobe. B, Axial CT shows multiple small cystic
lesions in the left lower lobe in type 2 CPAM. C, Coronal CT in
same patient shows multiple small cystic lesions in the left
lower lobe.

42. Type I cyst: Multiple air filled cysts
in left hemithorax, thin walled
cysts, C/L mediastinal shift.
CT: similar findings
Chest X-ray: right cystic hamartomatous/adenomatous
malformation type 1 with multiple cystic lesions in the right lower
lobe showing air-fluid levels consistent with infection. (B) Axial CT
scan through the lung bases show the thick-walled cysts in the right
lower lobe.

43. Pulmonary Sequestration
• Congenital mass of aberrant pulmonary
tissue that has no normal connection
with the bronchial tree or with the
pulmonary arteries.
• Artery: usually anomalous, from aorta
• Vein: Azygous system, pulmonary veins
or IVC
• Types: Intralobar and extralobar
• Usually asymptomatic, m/c
presentation is recurrent pneumonia.

44. Imaging in sequestration
• Identify sequestrated or dysplastic lung
• Identify aberrant arterial or venous connections
• Identify possible bronchial or gastrointestinal connections
• Exclude other associated lung anomalies, horse-shoe lung or
hypoplasia
• Assess diaphragm integrity
• Identify other associated anomalies

45. Contd..
• Ultrasonography: Neonate – mass adjacent to liver or diaphragm
• Antenatal USG: fetal chest mass with Doppler showing vascular
connections to the sequestration.
• CT:
• Intralobar - Multicystic mass at lung bases
• Extralobar – Soft tissue mass with avid contrast enhancement
adjacent to diaphragm
• MRI: Identification of pulmonary abnormality and vascular
connections in multiplanar.

46. Intralobar sequestration
• >common, 70-85%
• Within lung, no separate pleural covering, intimately connected to
adjacent lung.
• Venous drainage via pulmonary veins.
• Location: lower lobes (98%), medial part of left lower lobe – m/c.
• Anomalies <12%.
• Diagnosis at adolescence with recurrent or refractory pneumonia.

47. 2 round opacities overlying the left
cardiac border. They have no silhouette
with the left cardiac border, left
diaphragm or descending aorta
suggesting the left lower lobe location.
Mass in the left lower lobe with soft tissue
density (26 HU) , with defined border and
peripheral calcification. No visceral pleura
around the mass. No enhancement. arteries
directly from aorta, vein drain into
pulmonary v
well defined wedge shaped
echogenic lesion in right lower
lung. D/D – CPAM III , separate
feeding vessel from aorta

48. Extralobar Sequestration
• Less common, 15-25%
• Extrapleural, can be intrathoracic or extrathoracic, almost always left lower
lobe
• Presentation- early, neonate with cyanosis, respiratory distress, infection
• M:F = 4:1.
• Venous drainage via systemic veins into right atrium
• Separated from surrounding lung by own pleural covering.
• Associations: 65% - Pulmonary hypoplasia, horse-shoe lung, CCAM,
bronchogenic cysts, diaphragmatic hernia and CVS anomalies (TA and
TAPVR).

49. Left sided extralobar sequestration with a large
systemic vessel from aorta, coronal CT shows,
normal lung, beneath which left sided basal ELS
and draing vein into azygous below diaphragm

50. CHARACTERSTIC INTRALOBAR EXTRALOBAR
Incidence More common ( 75 %) Less common( 25 %)
Gender predisposition Equal Men 4: 1
Pleural investment Shares visceral pleura of parent
lobe
Separate visceral pleura
Location Lower lobes(98%) , medial part
of the left lobe
Above, below or within
diaphragm
Venous Drainage Pulmonary venous Systemic venous (azygos, IVC,
portal)
Presentation Early adulthood with a history
of pulmonary infection, chronic
cough, or asthma.
Asymptomatic mass (15%)
Mostly present during first 6
months of life
due to respiratory or
feeding problems
Radiographic
Features
Homogeneous
consolidation with
irregular margins or
uniformly dense mass
with smooth or lobulated
contours.
Single well defined,
homogeneous, triangular
shaped opacity in the lower
thorax. May present
else where in the thoracic
cavity.

51. DIAPHRAGMATIC ABNORMALITIES
• Hernia
• Eventeration
• Agenesis
• These anomalies associated with lung malformations and cause
severe respiratory symptoms

52. Bochdalek’s hernia
• Through the posteropleuoperitoneal foramen.
• Causes severe respiratory distress in the neonate .
• Involves the left pleuroperitoneal foramen in 75 % of cases.
• Neonatal radiograph shows a left-sided large intrathoracic mass of
soft-tissue density
• There is absence of the normal gas-containing bowel in the abdomen
which is usually scaphoid on examination and other developmental
abnormalities of the lung.
• Prognosis depends on degree of underlying lung hypoplasia.

53. The differential diagnoses are of other cystic-appearing intrathoracic
masses in the newborn
• Lobar emphysema,
• Cystic adenomatoid malformations.
• Sequestration,
• Bronchogenic cysts

54. 2 days old child showing a left-sided
congenital diaphragmatic hernia
with loops of bowel in the left
hemithorax and shift of the heart
and mediastinum to the right
Lateral chest X-ray shows bulge in diaphragmatic contour just
above posterior costophrenic recess. CT shows fatty mass
abutting the defect in posteromedial aspect of left
hemidiaphragm.

55. Congenital eventeration of the diaphragm
• Either partial or complete
• Nearly always left sided, due to
hypoplasia of the diaphragmatic
muscle.
• Most eventerations are minor,
transitory, local diaphragmatic
elevations found incidentally
within the first few years of life
Frontal and lateral chest x-ray shows smooth elevation of right
hemidiaphragm medially and anteriorly consistent with an
eventeration of the hemidiaphragm

56. Newborn chest

57. Immature lung disease
• Small, premature infants with clinical, radiological and prognostic features
differing from respiratory distress syndrome (RDS).
• Birth weight < 1500 gms.
• UNLIKE RDS, respiratory distress not seen until first 4-7 days.
• Insufficient surfactant.
• CXR: diffuse granularity of lungs, with relative absence of air bronchograms
and little or no underaeration of lungs (unlike in RDS).
• Complications: apnoea and bradycardia, persistent PDA
• Need ventillatory support
• Better prognosis compared to RDS (overall survival of 82%)

58. Respiratory Distress Syndrome
• Immaturity
• <2.5 kgs, <36 weeks gestation
• Leading cause of death in newborns
• Symptoms shortly after birth, chest wall retraction, cyanosis, grunting
• Deficiency of pulmonary surfactant.
• hallmark features: reticular granularity of the lungs due to superimposition
of multiple acinar nodules, related to atelectatic alveoli and diffuse
pulmonary under aeration.
• Air bronchograms due to coalescence of areas of atelectasis around dilated
terminal bronchioles
• Pulmonary interstitial emphysema: due to rupture of alveolar air sacs

59. Hyaline membrane disease. (A) Mild changes aged 1 day-fine
reticulonodular shadowing with prominent air bronchograms.
(B) More advanced changes aged 3 days-marked pulmonary
opacification with loss of diaphragmatic and cardiac contours.

60. Pulmonary Interstitial Emphysema
• also known as air block phenomenon.
• almost always preceded by postitive pressure ventilation.
• increase in transalveolar pressure leading to alveolar rupture
,dissection of air along peribronchial and perivascular spaces of
interstitium.
• tortuous linear luciencies of uniform size radiating from the hila
through the lungs.
• occurs in first week(CLD of prematurity usually in second week).

61. Pulmonary interstitial emphysema. Fine reticular
Shadowing in the right lung with deviation of the mediastinum
contralaterally. RDSaffecting the left lung.
Bilateral pneumothoraces in
hyaline membrane disease. Right
intercostal drain.

62. Bronchopulmonary dysplasia or chronic lung
disease of prematurity
• Complication of ventilation in newborn.
• Prolonged oxygen or ventilator therapy to developing lung.
• 4 stages of progression:
Stage I - ~ ARDS
Stage II: 4-10 days, Bilateral “white-outs” (necrosis, epithelial repair
with hyaline membrane, interstitial edema)
Stage III: 10-20 days, Bubbly appearance of lung (alveolar
overdistension)
Stage IV: after 1 month, Classic bubbly appearance with alternating
cyst like lucencies surrounded by curvilinear stranding of soft tissue.

63. Bronchopulmonary dysplasia. Patchy
shadowing from areas
of loss of volume and fibrosis, with areas of
compensatory emphysema,
especially in the right upper lobe.
Bilateral ill-defined reticulonodular markings, more prominent on the right,
with obscuration of the right hemidiaphragm and heart border, positive air-
bronchograms and hyperinflation of the left lower zone. No apparent atelectasis

64. Bronchopulmonary dysplasia (BPD). A, Axial CT in a patient with BPD shows heterogeneous attenuation containing
high attenuation and also areas of low attenuation. B, Axial CT shows bilateral multiple small cystic lesions in lungs of a
patient with BPD.

65. Transient tachypnea of newborn or wet lung
disease
• Delayed clearance and resorption of lung
fluid.
• Series of changes in X-ray:
• First 6 hrs, fluid within lungs with increased
vascular markings and hazy margins.
• AT 10-12 hrs, gradual clearance, reticular
granular densities ( ~ in RDS) but no
underinflation of lungs.
• At 48-72 hrs, gradual clearance from center to
periphery.

66. Meconium Aspiration Syndrome
• Cause: intrauterine or intrapartum aspiration of
meconium
• Secondary to intra-uterine hypoxemia
• Leads to bronchial obstruction and chemical
pneumonitis.
• Bilateral patchy asymmetrical areas of
opacification with marked overinflation.
• Complication: Pneumothorax and
pneumomediastinum.
• Radiological improvement lags behind clinical
improvement.
Meconium aspiration. There is marked overinflation
of the lungs with coarse nodular shadowing
secondary to meconium aspiration.
Bilateral chest drains drain pneumothoraces

67. Chest radiograph in a older child

68. Pulmonary infections
• Viral infections > bacterial
• Air trapping or atelectasis > common in children < 8 yrs (small caliber
peripheral airways, more collapsible and more mucus gland lining the
airways)
• Role of imaging: Confirm the presence, localization, extent and
complication.
• Not specific for specific organism.

69. Tuberculosis
• Primary TB causes localized air space disease (segmental or lobar) and
regional node enlargement.
• Occasionally, pleural effusion.
• Caseation and necrosis of lymph node or inflammatory focus can
occur (weeks later).
• Resistance leads to involution or calcification .
• Poor resistance or overwhelming infection, extension, larger area of
lung involvement with effusion.
• From lymphatic to venous system via thoracic duct leads to milliary
nodules.

70. 6 yr boy, presentation X-ray shows, tuberculoma right
lower lung, f/u X-ray 4 yr later, parenchymal calcification
with calcified nodes
Interstitial granular densities distributed
throughout the lungs, with relative basal and
apical sparing. No pleural effusions. No loss of
volume.

71. Inhaled foreign body
• May be radiopaque or non-radiopaque
• Tend to enter right main bronchus
• Complete obstruction – peripheral collapse
• Incomplete obstruction – obstructive emphysema
• Films in expiration or decubitus position and inspiration, if needed
fluoroscopy, mediastinal shift away from obstructive emphysema on
expiration/decubitus position (abnormal lung dependent).
• If clinical suspicion (negative radiograph) – Bronchoscopy.

72. Foreign body inhalation. (A) Obstructive emphysema from a
foreign body in the left main bronchus. (B, C) Another child
showing loss of volume in the left lung with patchy collapse in
the apex of the left lower lobe; in inspiration (B) the
mediastinum is slightly to the left; in expiration (C) the volume
of the left lung changes little with the mediastinum swingi
ng to the right.

73. Cystic fibrosis
• 2nd m/c chronic respiratory illness among children and young adults.
• Chr 7, cystic fibrosis gene, Autosomal recessive.
• Infants – atelectasis, focal or generalized overinflation with mucus
plugging partially obstructing the airway.
• Initial feature similar to viral pneumonitis.
• Older children – overinflation, bronchial wall thickening, dilatation
and mucus plugging – bronchiectasis.
• Bronchiectatic cavities – air-fluid levels.
• Hilar adenopathy, pulmonary hypertension.

74. • HRCT – Early changes, hallmark – extensive central bronchiectasis.
• Complication assessment:
• Pneumothorax
• Hemoptysis – source of bleeding identified by bronchial
arteriography.
• Cor-pulmonale and pulmonary hypertension.

75. Bilateral predominantly upper lobes bronchiectasis​ with
patchy consolidations and mild hyperinflation.
Bilateral severe, widespread bronchiectasis with occasional
mucus plugging and background mosaic attenuation, most likely
due to air trapping. Lung volumes are increased.

76. Cystic fibrosis. A, Coronal CT in a patient with cystic fibrosis shows extensive cystic bronchiectatic changes
predominantly seen in the upper lobes, along with bronchial thickening. The lungs are hyperinflated. B, Axial CT
in the same patient shows extensive bilateral upper lobe–predominant bronchiectatic changes along with
bronchial thickening and areas of mucoid plugging.

77. Idiopathic pulmonary haemosiderosis
• Unknown aetiology.
• Intra-alveolar hemorrhage.
• Acute hemorrhage – bilateral hazy
opacification ~ pulmonary edema
• After blood clears up, hemosiderin
deposited in lung septa – reticulonodular
interstitial pattern.
• Diagnosis: hemosiderin laden macrophages
in sputum.
Idiopathic pulmonary haemosiderosis. Perihilar
shadowing with a reticulonodular pattern in the
peripheral lung fields.

78. Pulmonary alveolar proteinosis
• Lipoprotenaceous deposits in alveolar spaces
• M;F – 2:1, ~ 20 years of age.
• CXR: multiple acinar nodules in miliary pattern, may coalesce, larger
areas of consolidation.
• CT: nodules more in dependent lung portions
• Histology: PAS positive staining

79. Fig. 9.25 (A) Pulmonary alveolar proteinosis. Chest X-ray showing
diffuse alveolar shadowing in a perihilar distribution with some fine
linear change in the upper zones. (B) High-resolution CT scan
confirming these appearances showing diffuse alveolar exudate with
interstitial thickening most marked in the non-dependent areas of
the lung.

80. References
• Textbook of Radiology and Imaging, David Sutton.
• RSNA articles Primary tuberculosis in childhood: radiographic
manifestations.
• Images from different web search.