Chest xray

1. IMAGE OF THE WEEK
M7 UNIT
PROF DR.THILAKAVATHI.R M.D
DR.MADHUSUDHANAN M.D
DR.ELANGOVAN M.D
BY DR.DHARANI L
(FIRST YEAR POSTGRADUATE)

2. CASE HISTORY
 A 45 year old male presented with
C/O cough with expectoration for 1 month
C/O decreased appetite
C/O hemoptysis – 2 episodes each around 2-3 ml
of blood in sputum

3. PAST HISTORY
 Not a known case of Pulmonary TB/T2DM/SHTN
 Not a known case of CVA, CAD, CKD
 No H/o covid 19 infection, both dose vaccinated
PERSONAL HISTORY
 Mixed diet
 Normal bowel and bladder habbits
 Known occasional alcoholic for past 10 years
 Known chronic smoker for past 20 years ( 1 pack
/day)

4. ON EXAMINATION
 Patient conscious
 Oriented
 Afebrile
 Hydration fair
 Clubbing – Grade II
BP- 120/70, PR- 108/ min, SPO2-96% in RA
CVS: S1S2 +, No murmur
RS: trachea in midline ,trial sign negative,
Normal vescicular breath sounds heard in all areas except left
supraclavicular and infraclavicular areas
Impaired resonance in left supraclavicular and supraclavicular
areas
VF, VR reduced in above areas
P/A: Soft, BS+, No organomegaly
CNS: No focal neurological deficit

5. CHEST XRAY PA VIEW

7. INTERPRETATION
 Frontal view of xray chest
 Full inspiratory film
 Adequate exposure
 Overpenetration present
 Trachea mildly deviated to left
 B/L lung field appears hyperinflated
 Mediastinum appears to be mildly shifted towards
left
 Left cardiophrenic angle appears to be blunted
 A heterogenous opacity noted in the left upper zone
with air around the opacity taking crescent shape

8. DIFFERENTIAL DIAGNOSIS
LEFT UPPER LOBE MASS
Tuberculosis
Single pulmonary nodule
Consolidation
Fungal ball- Aspergilloma
Abscess
Malignancy

9. CT CHEST

11. CT REPORT
 A well defined special soft tissue density mass of
4*3 cm in apicoposterior segment of left upper
lobe with eccentric air locule taking crescent shape
– suggestive of aspergilloma

12. INVESTIGATION
SPUTUM KOH MOUNT – Aspergillus fumigatus with
thin septate hyphae of acute angle
SPUTUM AFB – Negative

13. DIAGNOSIS
 A thin walled cavity with fungal ball aspergilloma –
probably post TB sequela

18. CT REPORT
 Fibrocavity measuring 3x2 cm in left upper lobe
apicoposterior segment with heterodense calcified
intracavitory body noted within the cavity
 Surrounded by crescent of air
 Multifocal patchy fibrosis noted in the left upper
lobe with traction bronchiectatic changes
 Possibly old infective sequela with fungal ball

19. SINGLE PULMONARY NODULE
 Well defined round or
oval </= 3 cm in
diameter surrounded
by pulmonary
parenchyma

20. CONSOLIDATION
 Airspace opacificaion
causing obscuration of
pulmonary vessels wih air
bronchograms

21. MALIGNANCY
 Round/ oval
opacities more
than 30 mm

22. LUNG ABSCESS
 Cavity containing gas fluid level
 Thick walled

23. CHRONIC PULMONARY
ASPERGILLOSIS
 It is a chronic progressive and destructive
parenchmal lung infection
 90 % in patients with current or previous underlying
lung disease or immune deficit
 Radiological presentation with formation of new
cavities or expansion of existing ones +/- fungal ball
or nodule

24. RADIOLOGICAL PHENOTYPES
 Simple aspergilloma
 Chronic cavitory pulmonary aspergillosis
 Aspergillus nodule
 Chronic fibrosing pulmonary aspergillosis
 Invasive pulmonary aspergillosis

25. RISK FACTORS
 Tuberculosis
 COPD +/- Emphsema
 Non – tuberculous mycobacterial infection
 Pneumothorax/bullous lung disease
 Allergic bronchopulmonary aspergillosis
 Pulmonary fibrocystic sarcoidosis
 Lung irradiation
 Rheumatoid arthritis
 Ankylosing spondylitis

27. ASPERGILLUS NODULES
 Occurs in immunocompetent hosts
 May be single/multiple with or without cavitation
 Patient are usually asymptomatic or have minor
pulmonary symptoms
 Aspergillus IgG titre may be rised
 Natural history is poorly described , but prognosis is
good

28. A SINGLE ASPERGILLOMA
 Single pulmonary aspergilloma is a single fungal
ball in a single pulmonary cavity
 Serological / microbiological evidence may
implicate Aspergillus spp
 No radiological progression over months of
observation
 Persistent pulmonary/ systemic symptoms
 Can be complicated by sudden , potentially fatal
hemoptysis
 MONAD SIGN – change of fungal ball position
within the cavity

30. CHRONIC CAVITARY PULMONARY
ASPERGILLOSIS
 Formation or expansion of existing cavities (usually
multiple ) is charecteristic
cavities may or may not contain an
aspergilloma ( fungal ball)
 Associated with high mortality (50-85% at 5 years)
cause of death include severe haemoptysis
and respiratory failure
 Mostly associated with underlying defect in innate
immunity

32. CHRONIC FIBROSING PULMONARY
ASPERGILLOSIS
 Extensive fibrosis with fibrotic destruction of atleast
two lobes of lung
 With major loss of lung function
 Represent an end result of untreated CCPA
 One or more aspergillomas may be present
 Seroloical/microbiological evidence is required for
diagnosis

33. INVASIVE PULMONARY
ASPERGILLOSIS
 Sub acute invasive / Chronic necrotising /
Semi invasive aspergillosis
 Airway invasive aspergillosis-
Bronchopneumonic aspergillosis
 Angio invasive aspergillosis

34. HALO SIGN
 Ground glass opacity
surrounding a
pulmonary nodule
represents
hemorrhage- in active
phase of IPA

35. AIR CRESCENT SIGN
 Half moon shaped lung tissue
 In recovery phase –peripheral absorption of
necrotic tissue causes the retraction of infarcted
area