This document provides an overview of an ongoing chest x-ray interpretation series aimed at promoting mastery of chest x-ray interpretation. It discusses several cases presented in the series, including a perforated gastric ulcer, pulmonary arterial hypertension, a ruptured diaphragm, cavitary tuberculosis, pneumocystis pneumonia with spontaneous pneumothorax, and lower rib fractures with an associated splenic injury. The goal of the series is to teach anatomy and common pathologies through case examples. Contributors to the series come from various medical centers and specialties around the world.

1. Adult Chest X-Rays Of The Month
Travis Barlock MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
January 2021

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/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 22-Year-Old
Male Presents
With Altered
Mental Status,
Sock, And A
Rigid
Abdomen.

8. Diagnosis: Perforated Gastric Ulcer With Tension Pneumoperitoneum
22-Year-Old
Male Presents
With Altered
Mental Status,
Sock, And A
Rigid
Abdomen.

9. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.

10. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.
The Chest X-Ray Is Read As Normal.

11. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.
A CT Scan Is Ordered And This Is Read As [-] For Pulmonary Embolus.

12. Let’s Go Back And Look At Her Images Again…

13. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.

14. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.
Enlarged Right
Descending
Pulmonary Artery
Enlarged Left
Descending
Pulmonary Artery

15. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.
Enlarged Right
Descending
Pulmonary Artery
Enlarged Left
Descending
Pulmonary Artery
Diagnosis: Pulmonary Arterial Hypertension

16. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.

17. 34-Year-Old Visiting From Out-Of-Town Presents With Worsening Dyspnea.
Enlarged Pulmonary Artery Diameter At The Bifurcation (Normal = 1:1 With The Aorta).

25. 29-Year-Old With A History Of Cocaine & Amphetamine Abuse Presents With Dyspnea.

26. Enlarged Right
Descending
Pulmonary Artery
Enlarged Left
Descending
Pulmonary Artery
29-Year-Old With A History Of Cocaine & Amphetamine Abuse Presents With Dyspnea.

27. Enlarged Right
Descending
Pulmonary Artery
Enlarged Left
Descending
Pulmonary Artery
29-Year-Old With A History Of Cocaine & Amphetamine Abuse Presents With Dyspnea.
Diagnosis: Pulmonary Arterial Hypertension

28. 40-Year-Old
Male Presenting
Following A
High-Speed MVC
Complains Of
Left-Sided Chest
Pain And
Dyspnea.

29. Diagnosis: Ruptured Diaphragm
40-Year-Old
Male Presenting
Following A
High-Speed MVC
Complains Of
Left-Sided Chest
Pain And
Dyspnea.

30. Diagnosis: Ruptured Diaphragm

31. Stomach
Stomach
Spleen
Spleen
Diaphragm
Diagnosis: Ruptured Diaphragm

32. Ruptured Diaphragm: Chest X-Ray After Repair.

35. Discontinuous Diaphragm Sign
The discontinuous diaphragm sign is present if there is visualization of direct
discontinuity of the diaphragm, along with segmental non-visualization.

36. Dangling Diaphragm Sign
The dangling diaphragm sign is present if the free edge of the torn diaphragm is
visible, curled inward away from the chest wall towards the central abdomen.

37. Collar Sign
The collar sign, also called
the hourglass sign refers to a
waist-like or collar-like
appearance of herniated organs
at the level of the diaphragm.

38. Intrathoracic Herniation Of Viscera
Intrathoracic herniation of
viscera is present if
intrabdominal organs are
visible within the thoracic
cavity through the defect in
the diaphragm.

39. Dependent Viscera Sign
The dependent viscera sign is present if the liver abuts the posterior ribs on the
right, and/or if bowel abuts the ribs, or lays posterior to the spleen on the left.

40. Contiguous Injury Across The Diaphragm
Contiguous injury across diaphragm implying transdiaphragmatic penetration,
is an indirect sign of (typically penetrating) diaphragmatic injury.
Hemothorax &
Lung Contusion
Liver
Laceration

41. Thickening Of The Diaphragm
Thickening of the diaphragm may be present at the site of injury with or
without retraction of the edges.

42. 39-Year-Old
Female From
West Africa
With A History
Of Tuberculosis
Presents With
A Recurrence
Of Hemoptysis.

43. 39-Year-Old
Female From
West Africa
With A History
Of Tuberculosis
Presents With
A Recurrence
Of Hemoptysis.
Finding: Air-Fluid Level

44. Diagnosis: Cavitary Tuberculosis

45. Diagnosis: Cavitary Tuberculosis

47. Tuberculosis Epidemiology In The U.S. 2017
• In 2017, the incidence of TB in the U.S. (2.8 cases per 100,000) was
the lowest since national surveillance began in 1952.
• The rate of TB among non-U.S.-born persons was 15 times the rate
among U.S.-born persons.
• The top five countries of birth of non-U.S.-born persons with TB were
Mexico (19%), Philippines (12.3%), India (9.4%), Vietnam (8.3%), and
China (6.3%).
• Persons who received a diagnosis of TB ≥10 years after arriving in the
U.S. accounted for 45% of all TB cases among non-U.S. born persons.

48. Tuberculosis Epidemiology In The U.S. 2017
• For those born in the United States, TB incidence was the highest
among Native Hawaiian/Pacific Islanders (5.6 cases per 100 000
persons), followed closely by American Indian/Alaskan Natives (4.0
cases per 100 000 persons).
• Individuals experiencing homelessness accounted for 4.1% of TB
cases, while 3.3% occurred among individuals who were incarcerated,
and 1.6% occurred among residents of long-term care facilities.

51. Background
• Patients with TB risk factors are often cared for at busy urban
hospitals with long wait times and crowded waiting rooms
• The ED is a high-risk are for M. tuberculosis transmission
• Most EDs do not have CDC-compliant TB isolation facilities
• Admitted pneumonia patients with and without TB may have long ED
wait times
• It is desirable to accurately differentiate pneumonia patients at very
low risk for TB from those for whom TB needs to be considered

52. Design
• Prospective case series conducted at 11 (EMERGEncy ID NET) academic
urban EDs with a combined volume of 900,000
• Participants were ED patients admitted with a diagnosis of pneumonia
or suspected TB
• The main outcome measure was derivation and validation of a sensitive
clinical decision instrument to identify patients not having TB (and not
requiring isolation) according to clinical data and chest radiographs.

53. Results
• Of 5,079 patients, 224 (4.4%) had pulmonary TB according to sputum
cultures or tissue staining.
• Instrument derived to predict which patient do not have TB:
No TB Or [+] PPD History Nonimmigrant Not Homeless
Not Recently Incarcerated No Recent Weight Loss No Cavitary Or Apical
Infiltrate On Chest X-Ray
NPV: 99.7[95% CI 99.1-99.9] Sensitivity: 96.4 [95% CI 91.9-99.9]

54. Conclusions
• The absence of all decision instrument criteria was highly predictive of
the absence of TB
• The decision instrument is not difficult to apply and it does not expend
additional resources in the ED
• Identifying low-risk patient may help preserve precious isolation beds
for higher risk patients

55. What About The CXR?
*Notice the high RR of TB associated with cavitation and apical infiltrate on CXR!
*
*

56. Punch Line?
• ALWAYS think about TB in your pneumonia patient who:
• Has a prior history of TB and/or a prior [+] PPD
• Is foreign born (see MMWR slides), homeless, and/or recently incarcerated
• Provides a history of non-volitional weight loss
• ALWAYS think about TB in your pneumonia patients with apical and/or
cavitary infiltrates on chest X-ray
When all of these historical and CXR finding are absent you can use a
validated clinical decision instrument to confidently conclude that your
pneumonia patient is not at significant risk for TB, and therefore will not
require respiratory isolation precautions.

57. Flowchart 1: Tuberculosis Algorithm for Countries With Incidence < 20 Cases per 100,000 Population
Flowchart 1: Tuberculosis Algorithm for Countries With Incidence < 20 Cases per 100,000 Populatio
IGRA = Interferon gamma release assay, TST= Tuberculin skin test
This algorithm is a visual representation of a portion of Tuberculosis Technical Instructions for Pane
Electronic Disease
Noti! cation System
Panel Physician Portal
nternational Adoption
International Adoption
Before you Travel
Overseas
Overseas Medical Exam
and Vaccinations
Class A Conditions /
Waiver Process
International Adoption
International Adoption
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Tuberculosis FAQs
Flowchart 2
Flowchart 1
Flowchart 1
4
4
Flowchart 1: Tuberculosis Algorithm for Countries With Incidence < 20 Cases per 100,000 Population
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Page last reviewed: August 6, 2019
Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
(NCEZID), Division of Global Migration and Quarantine (DGMQ)
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58. 48-Year-Old
With Known
Pneumocystis
Pneumonia
Presents With
Increasing
Dyspnea.

59. 48-Year-Old
With Known
Pneumocystis
Pneumonia
Presents With
Increasing
Dyspnea.
Diagnosis: Spontaneous Pneumothorax With Shift.
Collapsed
Lung

60. Spontaneous Pneumothorax After Pigtail Placement.
In Patients With
Pneumocystis
Pneumonia,
Spontaneous
Pneumothorax Is
Thought To Be
The Result Of
Severe Lung
Necrosis And
Alveolar
Rupture.

61. 50-Year-Old In
A Rollover
MVC Who
Presents With
Left-Sided Rib
Pain.

62. 50-Year-Old In
A Rollover
MVC Who
Presents With
Left-Sided Rib
Pain.
A CT Scan Of
The Chest Was
Obtained.
Rib
Fractures
8, 9, 10

63. Diagnosis: Posterior Rib Fractures

64. The Lower Cuts Of The Chest CT Demonstrate A Splenic Injury.

65. Abdominal CT Defines The Injury – A “Contrast Blush” Is Managed With Angio-Embolization.

66. Rib Fractures And Solid Organ Injuries
• Left and right sided fractures of the middle rib segments (5 to 8)
and lower rib segments (9 to 12) are associated with injuries of the
spleen and liver respectively.
• The data on the number of rib fractures and the likelihood of solid
organ injuries is mixed.
• There is currently no decision instrument allowing clinicians to
exclude solid organ injury in rib fracture patients by physical exam
alone.
Rostas JW. The American Journal of Surgery. 2017; 213:791-797.
Kessell B. Injury. 2010; 45(5):855-858.
Shweiki E. The Journal of Trauma, Injury, Infection and Critical Care. 2001; 50:684-688.

67. Summary Of Diagnoses This Month
 Perforated gastric ulcer with tension hemoperitoneum
 Pulmonary arterial hypertension
 Ruptured diaphragm
 Cavitary tuberculosis
 Pneumocystis pneumonia with spontaneous pneumothorax
 Lower rib fractures and an associated splenic injury

68. See You Next Month!