new resp toacs by dr shariq radiology

1. RESPIRATORY SYSTEM
Dr. Syed Shariqullah
Consultant Radiologist
MBBS, FCPS

2. Objectives for Exams
• IMM exam is based on writing stuff. Following are the main points in which you will be
judged: Modality, Radiological findings, Diagnosis, Differential diagnosis and Next
investigation.
• Kindly mute your microphones during the session.
• Everyone should speak in this platform via chat box or by unmuting their microphone (one
by one) and for any query just raise your hand.
• Do not interfere in others turn while he or she is describing the film.
• Do not jump to a diagnosis until you are very sure.
• Build a case step by step.
• Continue your thought process and lateral thinking.
• Come to few differential diagnosis first.
• With confidence: the most likely diagnosis.
• If you are blank on any film, then comment on the negative findings during which you buy
enough time to look for any pathology.
• 40 stations (20 Systems 20 anatomy & physics). Passing marks is 60%(according to CPSP).

4. Liver Abscess
Study: chest x ray frontal projection
Description:
a well defined rounded lucency with air fluid level is seen in right hypochondrium below diaphragm
causing elevation of right hemidiaphragm Rest of the study was unremarkable.
Diagnosis: Liver abscess
Differential Diagnosis
1. chiliditi syndrome
2. gut herniation
What next:
1. History
2. Ultrasound abdomen
3. Iv antibiotics
4. Percutaneous aspiration can be offered

5. Pneumoperitoneum
• Study: CXR frontal projection
• Description: streak of air lucency under the right hemidiaphragm with no
calcification air fluid level or air bronchogram seenb
• The rest of the lungs appear normal
• No bony abnormality/fracture noted
• Cp angles are clear
• Cardiac size appears normal
• no signs of pneumopericardium
• Diagnosis: pneumoperitoneum
• Differentials:
• What next:

7. Hidden areas on CXR
• Hidden areas on lung include
• Lung apices----Obscured by ribs
• Hilar vessels ---obscuring lungs anteriorly & posteriroly
• Lung posterior to diaphragm
• CP Angles----Obscured by cardiac shadow

9. Posterior mediastinal masses
• Study: Chest xray frontal projection
• Description: a well defined round opacity in the right paratracheal
region making an obtuse angle with the mediastinum. Hilum overlay
sign positive. No air bronchograms calcification or air fluid level
noted. Lateral x ray confirmed opacity located in posterior
mediastinum.
• Diagnosis: Could be a mass of anterior or posterior mediastinum
• Differentials: Masses of posterior mediastinum
• What next: Further confirmed by a lateral chest x ray

11. Bilateral hilar lymphadenopathy
Study:
Description:
Diagnosis:Pulmonary bronchocele
Differentials:
What next:

13. Stage II sarcoidosis with nodal and
parenchymal disease.
Study: Plain radiograph chest frontal projection
Description: upper zone reticulonodular opacities with widening of
right paratacheal stripe and bilateral enlarged hila suggesting
extensive mediastinal and hilar nodal enlargement.
Diagnosis: Stage II sarcoidosis with nodal and parenchymal disease.
Differentials:
What next:
serum ACE levels
Scinitgraphy gallium 67 scan

15. • Hrct shows multiple interstitial Nodules in subpleural location, along
fissures, along interlobular septa, and adjacent to the
bronchovascular bundles. There are few dilated thickened bronchi in
both lung. Dx : sarcoidosis dds: lymphangitic carcinomatosis.silicosis .
Pneumoconioisis

17. Scintigraphy in sarcoidosis
• Gallium-67 scan showing bilateral tracer uptake in the parotid and
lacrimal glands - the panda sign of sarcoidosis.
• Bilateral hila and right paratacheal uptake of gallium give lambda sign
of thoracic sarcoidosis

19. Right upper lobe collapse .
First image : A well defined homogenous radiopacity seen in right upper
zone obscuring the medial cardio mediastinal border . There is no
calcification, cavitation, air fluid level or overlying bony erosion. there is
loss of lung volume on right side . The horizontal fissure is elevated with a
convex border, golden S sign is demonstrated. There is some elevation of
right hemidiaphragm as well and the spared lung field appear a little more
translucent suggesting hyper inflation. Left hemithorax is normal
Diagnosis: right upper lobe collapse.
Differntials : consolidation / lung mass /
What next:
Bronchoscophy
CECT chest

20. Left upper lobe collapse
• Study: Chest x ray frontal projection.
• Description: There is loss of left lung Volume. A hazy or veiling
opacity is seen extending from hilum and fading out inferiorly. With
obscuration of normal cardio mediastinal contour. A sickle shaped
lucency is seen medially outlining the aortic arch giving luftschial sign.
• Diagnosis: left upper lobe collapse.
• Differentials. Consolidation.
• Next ct chest

21. 6 Signs of lung collapse
• Elevation of diaphragm
• Depression of hilum
• Crowding of ribs
• Compensatory hyperinflation.

23. RML collapse

25. • All cases of fluid overload
• Pulmonary edema
• Sarcoidosis

27. • X ray chest frontal projection* a well defined rounded soft tissue
density pleural based nodule of size about less than 3mm seen in left
upper zone, no synchronous lesion identified in rest of the lung Fields.
cardiomediastinum is central.Bilateral Cp angles are clear.Diagnosis:
Solitary nodule in Left lung likely granulomaNext': History of patient
and follow up after 6 month's

28. • 2nd imageCXR Frontal projection of a female patient.Multiple
rounded soft tissue density nodules of almost similar sizes seen
scatterd in bilateral lung fields giving cannon ball appearnce no
calcificatio n caviataion or air fluid level seen.No septal thickening
seen.Bilateral Cp angles are clear.Diagnosis Pulmonary metastais Next
: History of patientUltrasound Abdomen and pelvisCECT chest

30. Solitary cavity Right lung
• Study: CXR frontal projection
• Description: A Well cavitatory lesion seen in right upper lobe with
thick irregular walls and air fluid level. No soft tissue component
seen. No hilar adenopathy Rest of the lung field appear
Unremarkable.
• Diagnosis: Lung abscess
• Differentials: squamous cell Ca
• What next: Antibiotics, Follow up

31. Multiple cavities bilateral cavities
• B. X ray chest frontal projection showing multiple well defined thin
walled cavitating lesions, with air fluid levels, in left upper and mid
lung zones. Rest of the lung fields appear unremarkable.No soft tissue
component or hilar lymph nodes seen.No calcification or air
bronchogram seenCP angles are clear. Cardiac size is not enlarged.
• Diagnosis: post traumatic cavities
• Differentials:
1. CCAM
2. bronchogenic cyst

33. Tension pneumothorax
• X ray chest frontal projection showing hyperlucent left hemithorax
with loss of pulmonary vascular markings, there is widening of
intercostal spaces. Trachea is deviated to the right side. Mediastinal
shift to right. Depression of left hemidiaphragm. No overlying bone
destruction seen.
• Dx: tension pneumothorax
• Differntials:
1. Poland syndrome
2. Mcleods symdrome
• Next: chest intubation

35. Hypertransradiant left hemi thorax.
• A. X ray chest frontal projection showing hyperlucent left lung.
Axillary fat pad is seen more mared on left, abdent breast shadows
seen on left side.
• No hilar lymphadenopathy seen.Trachea is central. CP angles are clear.
Cardiac size not enlarged.
• Dx: Poland syndrome
• DD:
1. Mcleods syndrome
2. Mastectomy

36. • B) . X ray chest frontal projection showing hyperlucent left lung. Left
hilum is smaller as compared to right. There is decreased vascularity
of left lung.Trachea is central. CP angles are clear. Cardiac size not
enlarged.Dx: Mc Leods syndromeDD: Poland syndrome

38. hamartoma
• A. X ray chest frontal projection showing a well defined opacity in
right upper lung zone showing popcorn calcification. No air
bronchogram, cavitation or air fluid level seen. Trachea is central. CP
angles are clear. Cardiac size not enlarged.
• Dx: Hamartoma
• D/D
1. lipoma
2. Angiolipoma
3. granuloma
• Next: HRCT chest. follow up after 6 months to check variation in size.

40. Mesothelioma
• A. X ray chest frontal projection showing pleural based opacity,
forming obtuse angle with lung, extending from upper lung zone to
the CP angle, causing scalloping of the lung. The right lung shows
multiple i ll defined opacities, more at the base causing shaggy heart
border. Horizontal fissure is prominent. Volume of right hemithorax is
reduced.CP angles are clear.
• Dx: mesothelioma
• DD: loculated pleural effusion/ empyema
• Next: HRCT chest

41. • CT chest axial slice, mediastinal window, showing soft tissue pleural
based density in right lung zone extending from anterior chest wall to
posterior chest wall. No vascular or bony invasion. No
lymphadenopathy

43. Neuroenteric cyst
• MRI chest coronal view showing well defined, high signal intensity
lesion in posterior mediastinum along the right para vertebral space.
• Dx: neurenteric cyst
• DD: paravertebral abscess

45. pulmonary thromboembolism
• X ray chest frontal projection showing a wedge shaped opacity at left
CP angle - Hamptom hump. Westermark sign is positive. Rest of the
lung fields are clear. Trachea is central. CP angles are clear. Cardiac
size not enlarged.
• Dx: pulmonary thromboembolism
• Next:
1. V/Q scan
2. CT angiography

46. pulmonary thromboembolism
• B. CT chest axial slice, mediastinal window, showing mutliple filling
defects in bilateral pulmonary vessels indicating multiple emboli in
pulmonary vasculature.
• Dx: pulmonary thromboembolism
• Next:
1. V/Q scan
2. CT angiography

48. • V/Q scan
• Multiple bilateral wedge shaped perfusion defects noted in lung
parenchymaNormal ventilation noted on ventilation scan
• Diagnosis: pulmonary embolism
• Differentials: pulmonary aneurysm,extrinsic tumor compressing
pulmonary artery
• What next:
1. CXR to see for parenchymal changes
2. Ct chest with contrast
3. CTPA
4. Ultrasound lower limb doppler

49. Signs of pulmonary thromboembolism
• Humpton’s hump
• Polomint sign
• Westernmark sign
• Peripheral vascular pruning

51. Pectus excavatum
• Chest xray frontal projectionStraightening of right heart border and
right paratracheal stripeSplaying and straightening of posterior
ribsVertically oriented anterior ribMildly Hyperinflated
lungsDiagnosis: pectus excavatumWhat next: patients history
takingHrct

53. Slide number 23 A
• ct chest with contrast axial image mediastinal windowA soft tissue
density/hypodense mass with a speck of calcification within is seen
arising in the anterior mediastinum abutting the svc and partially
infiltrating itMass seem to abut the ascending aortaNo cavitation or
air fluid level seenMargins are well definedNote is made of small
volume lymphadenopathyDifferntials: anterior mediastinal
massesDiagnosis: anterior mediastinal mass likely teratomaWhat
next: ct chest with contrast to see the enhancement further
confirming the diagnosisCt neck to rule out any thyroid mass or
possibiltyTo chek the lung windows for any pulmonary changesUsg
pelvis

54. Slide no 23 (b):
• ct chest with contrast axial image mediastinal windowA well defined
round hypodense mass is seen in the right paratracheal region with
no calcification cavitation or air fluid level seenThe mass seem to abut
the posterior parts of svc and ascending aorta along with the anterior
aspect of tracheaDifferntial: middle mediastinal masses
• Diagnosis: Bronchogenic cyst
• What next: inform the physician for this incidental finding To look for
lung changes in lung window

55. Slide no 23 (c):
• CT chest with contrast axial section mediastinal window, a well
defined hypodense mass is noted in the posterior mediastinum
abutting the desending aorta and vertebral body No
calcificatin/cavitation/air fluid level appreciated
• Differential: posterior mediastinal mass
• Diagnosis: thoracic neuroblastoma
• What next: MRI, MIBG, FDG PET, Tc 99 m MDP

57. Esophageal abscess
• chest xray frontal projectionShows a small well defined opacity in the left
mediastinal region near the aortopulmonary window having a compression
effect on trachea and shifting it towards right sideNo calcification
cavitation or air fluid level noted withinRest of the lung fields appear
unremarkableCp angles are clear and no bony abnormality notedCardiac
size appear normalDiagnosis: esophageal abscess/ esophageal
mass/esophageal cystWhat next: barium swallow,ct neck n chest with
contrastThis is further confirmed on a lateral xray of cervical spine showing
a radiolucency infront of C5-C7 vertebrae that is causing forward bowing of
trachea and seem to be arising from mediastinum below the clavicles no
calcification/foreign body/bony fragment appreciatedCould be a
prevertebral abscess/esophageal abscess

58. Mediastinal lipomatosis
• Study: ct chest with contrast axial image mediastinal window
• A hypodense lesion/mass is seen with a density almost equal to that
of surrounding chest wall fatIt seems to have compression effect on
left main bronchus and bilateral hilar vesselsIt is abutting the left
cardiac contour mainly. No calcification/cavitation/air fluid level noted
Diagnosis: Findings suggest mediastinal lipomatosis
• Differentials:
• What next: Can further be confirmed on MRI fat sat images

60. Pneumomediastinum
• chest x ray frontal projectionShows multiple streaks of air lucencies in
the soft tissues of neck suggestive of subcutaneous
emphysemaLucencies are also appreciated around pulmonary artery
and main branches giving ring around artery sign Air lucencies are
seen outling tracheal region and bronchi giving double bronchial wall
sign Diagnosis: pneumomediastinumWhat next: inform the
surgeon/physician HRCT

61. pneumopericardium
• chest x ray frontal projection of a neonateShows a crescenteric air
lucency around pericardium with no calcification within Umbilical
artery and venous catheters are noted in situDiagnosis:
pneumopericardium

62. Mediastinal hematoma
• ct chest with contrast axial image mediastinal windowShows bilateral
pleural effusion more marked in right pleural cavity There is a patch of
consolidation in the medial segment of right middle lobee A
hypodense collection is noted in mediastinum abutting the svc and
aortaNo calcification cavitation air fluid level noted
withinHypodensities are noted in left pectoralis major muscle
suggestive of subcutaneous emhphysema along with a small
hypodense collection anterior to body of sternum with surrounding
fat strandingDiagnosis: mediastinal hematoma due to interventional
procedure What next? Inform the physician or surgeonPleural
tapChest intubation

64. Fibrosisng mediastinitis…post radiation
• chest x ray frontal projection shows multiple fibrotic strands
emanating along both sides of the mediastinum causing widening of
right and left paratracheal stripes Fibrosis of trachea and esophagus
as both of them are not visualized Lung fields cardiac size and cp
angles are clearCt chest non contrast axial section lung window shows
fibrotic scarring of mediastinum abutting the svc,aorta and both
bronchi also causing widening of mediastinum Diagnosis: mediastinal
fibrosisWhat next? Ultrasound abdomenUltrasound orbitMri
orbitsMrcp

66. Atypical thymoma
• : Ct chest with contrast axial images mediastinal window show a
hyperdense/solid density lesion in the anterior mediastinum with a
focus of calcification within no air bronchogram no air fluid level
presentThere are lobulated hyperdense lesions in the adjoining
mediastinal and diaphragmatic pleura also that contains no focus of
calcification within Now because of its solid density anterior
mediastinal mass would be thymoma n when calcification is seen
within it it wud more likely be a teratoma
• Diagnosis: malignant teratoma
• What next? Usg scrotum Usg pelvis in femalesCt abdomen with
contrast

68. Anterior mediastinal teratodermoid
• Cxr frontal projectionShows a well defined soft tissue density round mass
abutting the left cardiac border and making an obtuse angle with the
mediastinal contourHilum overlay sign positive Speck of calcification
notedNot abutting the descending aorta marginsDiagnosis: anterior
mediastinal mass most likely teratomaOn ct unenhanced axial section med
window shows a large hyodense mass on left side arising from the anterior
mediastinum with specks of calcification and fat density withinScaloping of
lung marginsNo cavitation or air fluid level notedThe mass has compression
effect on aorta and left main bronchus causing mild contralatetal
mediastinal shift.
• Diagnosis: anterior mediastinal teratodermoid
• What next: biopsy and MRI

70. Cystic Hygroma/Cystic lymphangioma
• Study: CECT root of neck & upper chest, soft tissue window axial slices.
• Description: Well defined cystic lesion with fluid attenuation, internal
septtaion & enhancement of walls. Extending from root of neck it is
infiltrating into the para pharyngeal spaces & tracheoesophageal region.
Posteriorly it is abutting the spine, anteriorly abutting the clavicle,
infiltrating into the chest cavity.
• Diagnosis: Cystic Hygroma/Cystic lymphangioma
• Differentials:
1. Perforated ruptured abscess.
2. Closed confined abscess
• Next investigation: MRI (just to see fluid-fluid, fat fluid levels).

72. Epicardial fat pad
Study: X ray chest frontal projection & CECT chest mediastinal window, Axial Slice
Description: Xray: Triangular opacity is seen involving right costophernic angle
Loss of silhouette with the diaphragm,
CT: fat density is seen adjacent to right heart border
Diagnosis: Epicardial fat pad
Differentials:
1. Mediastinal lipomatosis
2. Morgagni hernia
What next: CXR lateral view
CT chest (if x-ray is given)

74. Study: CXR frontal projection & CEXT chest mediastinal window axial image.
Description: X ray: Air lucencies forming a confined space at right
cardiophernic angle
With slight contra lateral mediastinal shift, extending to bronchus
No evidence of calcification, cavitations, or air fluid level
CT: hepatic flexure is seen in left hemithorax with mottled lucencies,
Diagnosis:
Differentials:
What next:

76. Esophageal Achalasia
Study: X ray chest AP & lateral view
Description: retrosternal tubular air lucnecy withh air fluid level is seen extending from superior to inferior medistinum
there is widening of superior mediastinum, loss of stomach bubble in its normal location, no evidnec of elecation or
depression of diaphragm.
Lateral CXR: shows this opacity lies in posterior mediastinum.
Diagnosi:
Differentials:
1. Esophageal web,
2. Esophageal stricture
3. Esophageal carcinoma
4. Esophageal atresia
What next:
Barium swallow
CT chest

78. Gastric herniation
Study: Chest X-ray frontal projection
Description: Well defined air lucnecy occupying, closed confined space in
retro cardium. There is unfolding of aorta, calcified aortic knuckle, elevated
hemidiaphragm, absence of stomach shadow in normal location.
Diagnosis: Gastric herniation
Differentials: Inferior mediastinum lesions,
Anterior: thymoma, teratoma, thymolipoma, thymic hyperplesia
Middle: Achlasia, epiphernic diverticulum, gastric volvulus, diaphramtic
hernia. Sliding or paraesophageal rolling hernia, Mediastinal abscess
Posterior:
What next: CECT chest, abdomen

80. Bronchogenic cyst
Study: Chest x ray frontal projection
Description: well defined sharply marginated opacity is seen, involving the
middle mediastinum, causing scalloping of the right lung margin, no
evidnece of any calcification, cavitation, air fluid level.
CT scan: Fluid density lesion causing splaying of both bronchi, causing
forward bowing of trachea,
Diagnosis: Bronchogenic cyst
Differentials:
1. necrotic lymph nodes
2. Mediastinal hydatid cyst.
What next:

81. Neuroenteric cyst
Study: CECT chest mediastinal window, axial image.
Description: Fluid density is seen in posterior mediastinum it is causing
forward bowing of trachea
Differentials:
Paravertebral abscess
Extramedullary hematopoisis
What next: Blood profile for thalasemia, sickle cell
anemia

83. Mediastinal lymphoma
Study: Chest x ray frontal projection.
Description: Multiple nodular opacities causing widening of both para
tracheal stripes, lung involvement intrapulmonary opacities.
1st CT image: Discrete nodes
2nd image: Nodes are confluent together
3rd image: Conglomerate nodal mass
Diagnosis: Mediastinal lymphoma
Differentials:
1. Tuberculosis
2. Sarcoidosis
3. Metastasis
What next:

85. Aortic aneurysm
Study: Chest x ray frontal projection of an adult patient
Description: well defined, sharply marginated opacity with good lateral
margins & indistinct medial margins is seen along arch of aorta
causing significant contra lateral shift of trachea with scalloping &
inferior displacement of left main bronchus. Blunting of left CP angle,
cardiomegaly
Diagnosis: Aortic aneurysm with cardiomegaly & left pleural effusion
Differentials: Aortic dissection
What next: Echocardiography
CECT chest/Ct angiography of aorta

86. FALSE
LUMEN
TRUE
LUMEN
Type A d standford,
de bakey type II

87. Aortic dissection
Study: CECT of same patient mediastinal window
Description: Intimal flap which is dividing ascending aortic lumen into
two halves,
Diagnosis: Aortic dissection stanford A or de bakey II
Differentials:
What next:

89. Debakey & stanford classification of aortic
disscetion
• De bakey type 1: Ascending & descending
• De bakey Type 2: ascending only
• De bakey type 3, descending only
• Stanford A= Aortic arch, Ascending aorta (Arises at Ascending aorta,
Arch of aorta)
• Stanford B= Descending only (Begins Beyond Brachiocephaic artery)

91. Posterior mediastinal mass
Study: X ray chest frontal & lateral projections, CECT chest mediastinal
window, axial images.
Description: Frontal : a well defined opacity is seen in the right perihilar
region with positive hilum overlay sign, lateral image: cavity in
posterior mediastinum.
CECT chest:
Diagnosis: Posterior mediastinal mass
Differentials: Small paravertebral abscess, neurogenic tumor (widening
of neural foramina).
What next:

92. Neuroblastoma
• posterior mediastinal lesion causing erosion & destruction of
posterior ribs, extending into the spinal canal,
• showing calcifications.
• Differentials:

94. Paravertebral abscess
Study: CECT chest soft tissue window coronal & axial image, MRI chest
sagittal image.
Description: a well defined lesion in right paravertebral region, no
calicifation, cavitation or air fluid level seen, it is having enhancing
walls, erosion & destruction of adjacent vertebral bodies, a few
pneumonitic changes in adjacent lung.
Contrast enhanced MR image shows enhancing walls with necrotic
center.
Diagnosis: Paravertebral abscess
Differentials: Pott’s disease (bilateral paravertebral abscesses with
calcifications & gibbous deformity, Koch defects)

96. Extramedullary hematopoiesis
Study:
Description: Soft tissue density lobulated paraspinal masses are noted. Ribs
appears widened with reticular pattern of medullary cavity .No lung lesion
identified Cardiac shadow is unremarkable .?
Diagnosis: Extramedullary hematopoiesis
Differentials: paraspinal TB Multiple neurofibromas
What next:
1. History for blood disorders
2. CT chest with IV contrast
3. Bone marrow Biospy.

98. Pleural effusion vs. empyema
Study:
Description: Bilateral plural effusion , moderate on right and mild on
left.
Diagnosis: Pleural effusion vs. empyema
Differentials:
What next:

99. Empyema
• A fluid density crescenteric shaped lesion arising from chest wall
making an obtuse angle with thickened enhancing pleura suggestive
of split pleura sign. There is alight compressionof underlying lung
parenchyma.
• Diagnosis: Empyema
• D/D: mesothelioma
• Next : IV antibiotics.CT guided aspiration.

101. Bronchopleural fistula
Study: Xray chest
Description:Xray chest serial images are provided . shows air fluid level
with interval increase in air lucency and interval incraese in the air in
fluid level suggestive of bronchopleural fistula.
Diagnosis: Bronchopleural fistula
Differentials:
What next: CT and nucleur medicine study

103. Pulmonary asbestosis
Study:
Description: Xray chest frontal projection of skeletally mature patient is
provided showing multiple calcified pleural based plauqes in costal ,
diaphragmatic and mediastinal pleura with calcified opcities in bilateral
lung giving clover leaf appearance .Reticular bands are seen in bilateral
lungs.
Diagnosis: Pulmonary asbestosis
Differentials:pleural based mesothelioma, fibroma , chest wall tumors,
pleural based mets
What next: HRCT , follow up with Xrays , biopsy.

105. Hypertrophic pulmonary osteoarthropathy
Study: X ray chest frontal projection, X ray right leg frontal view & Selected
CECT image axial view-mediastinal window
Description: CXR: well defined opacity causing significant elevation &
collapse of right lung with, contralateral deviation of trachea.
CECT: shows a calcified pleural based lesion with necrosis, it is invading the
mediastinal pleura & descending thoracic aorta. There is evidence of lung
collapse….pleural based fibroma
X ray limb: lamellated periosteal reaction along shaft of tibia & fibula
Diagnosis: Hypertrophic pulmonary osteoarthropathy
Differentials:
What next: xray limb…Skeletal survey & CXR

106. • Squamous  Smoker, Cavitate, central, poor prognosis
• Adenocarcinoma  Women, Non smoker, peripheral
• Large cell  >4cm, smoker, peripherally locatedd
• Small cell  Smoker, metastasize earlier (worst prognosis),
Paraneoplastic & SVC syndrome.
• Metastatic potential  Small > Adeno > Large > Squamous

110. Cavitating tumor and right upper lobe collapse
(Golden S sign)
Study:
Description:
Diagnosis:Cavitating tumor and right upper lobe collapse (Golden S
sign)
Differentials:
What next:

113. Lymphangitic carcinomatosis
Study:
Description:
Diagnosis:Lymphangitic carcinomatosis
Differentials:
What next:

114. SOME TUMORS SPREAD BY PLUGGING
LYMPHATICS

117. Pulmonary bronchocele
Study:
Description:
Diagnosis:Pulmonary bronchocele
Differentials:
What next:

120. Pancoast tumor
Study:
Description:
Diagnosis:Pancoast tumor
Differentials:
What next:

123. Varicella infection
Study:
Description:
Diagnosis:Varicella infection
Differentials:
What next:

126. Round pneumonia
Study:
Description:
Diagnosis:Round pneumonia
Differentials:
What next:

129. Lipoid pneumonia
Study:
Description:
Diagnosis:Lipoid pneumonia
Differentials:
What next:

132. Aspiration pneumonia
Study:
Description:
Diagnosis:Aspiration pneumonia
Differentials:
What next:

134. Peripheral opacities (Loffler's syndrome)
Study:
Description:
Diagnosis:Peripheral opacities (Loffler's syndrome)
Differentials:
What next:

136. Hydatid disease
Study: CXR frontal projection
Description: shows 2 well defined large opacities in the right upper mid and
lower zones and another opacity with air fluid level in the left lower zone
with obliteration of left cp angle no calcification no bony erosion seen
cardiomediastinal contour is normal
Diagnosis: findings are consistent with pulmonary hydatid cysts and left
sided cyst with bronchial communication
Differentials
1. lung abcess
2. bronchogenic cyst
3. pul sequestration
What next: CECT chest

137. • Chest xray frontal projection shows thick walled well defined cavitory
lesion in right lower zone with air fluid level and membrane seen
floating in it forming water lilly and camelot sign no wall calcifications
no bony erosion see

138. Study:
Description: Selective contrast enhanced axial slice shows a well
defined thin wall cystic lesion with no enhancement and air fluid level
seen in it adjacent to the right mediastinum with fat plan well
preserved
Diagnosis: Diagnosis most likely pul hydatid cyst with bronchial
communication
Differentials:
What next:

140. • image a and b Chest xray frontal projection shows multiple
radioopacites in bilateral lower zone no calcification no bony erosion
no pleural effusion seen cardio mediastinal contour is central further
contrast enhance ct of shows fluid density well defined lesions with
subtle wall enhacement in bilateral lower zones peripheral region no
wall calcifications seen Diagnosis hydatid cyst

141. Hydatid signs
• Selective contrast enhanced axial slice shows a well defined thin wall
cystic lesion with no enhacement and air fluid level seen in it adjacent
to the right mediastinum with fat plan well preserved Diagnosis most
likely pul hydatid cyst with bronchial communication

142. Image D-Hydatid Signs
• Axial ct scan shows cystic mass containing multiple daughter cysts
(hydatid cyst)

144. Kartagners syndrome
Study: Chest xray frontal projection
Description: Chest xray frontal projection It shows the apex of the
heart directed towards right side stomach gas bubble is also on the
right side bilateral upper lobes shows tram track opacites extending
from hilum to the upper lobes suggesting bronchiectasisBilateral
lower lobes shows reticulations
Diagnosis: Kartagners syndrome
Differentials: situs solitis
What next: Fertilty workup

145. Intralobar sequestrations
Study: Chest xray frontal projection
Description: It shows inhomogeneous opacity with air fluid level in the
right cardiophrenic angle however sillhoute is intact
Diagnosis: Intralobar sequestrations
Differentials: Ddx lung abcess intralobar sequestration
What next: Next CTA and conventional Cather angiography to see
separate blood supply

146. • Coronal cect shows a solid mass in the right lower zone deriving its
blood supply from decending thoracic aorta Extralobar seq

148. Study:
Description: shows a nodule with surrounding air lucency forming
monad / air crescent sign in right upper zone no calcification no bony
destruction seen
Diagnosis: Diagnosis mycetoma
Differentials: hydatid cyst actinomycosis
What next: CECT chest

150. Tracheoesophageal Fistula
Study:
Description:
Diagnosis:Tracheo esophageal Fistula type
Differentials:
What next

152. epiglottitis
Study:
Description: Lateral radiograph of neck using soft tissue technique
demonstrates enlarged eppiglottis giving thumb Sign with markedly
thickened aryepiglottic fold and narrowing of subglottic portion of trachea.
Ballooning of hypophyrnx and pyriform sinuses with reversal of normal
lordotic curve of cervical spine
Diagnosis: eppiglottis. steeple sign, also called the wine bottle sign, refers to
the tapering of the upper trachea on a frontal chest radiograph.
Differentials: croup, enlarged adenoids
What next:

153. Croup
• Eppiglottis appear normal The appearance is suggestive of croup,
which should be obvious clinically. A corresponding lateral x-ray
would show narrowing of the subglottic trachea and ballooning of the
hypopharynx.

155. Bronchial atresia
Study: CXR FRONTAL PROJECTION
Description: showing hyperlucency of the left upper and mid zone without
hyper expansion or volume loss. Central branching opacity radiating away
from left hilum is seen. No pneumothorax. No consolidation or pleural
effusion. Heart size and contour appear normal. Right lung appears normal.
Diagnosis: Bronchial atresia
Differentials:
1. congenital lobar emphysema
2. Congenital pulmonary airway malformation
3. ABPA
What next: Ct CHEST

156. • CT chest axial view showing focal area of hypoattenuation involving
much of the left upper lobe. There is decreased vascularity within this
hyperlucent segment. No evidence of overexpansion of the lobe.
Right appears norma

158. Egg shell calcification in silicosis and PMF
Study: CHEST x ray frontal projection
Description: shows large symmetric bilateral opacities with irregular margins in the upper lobes
extending towards hilum . CP angle appear normal.
Diagnosis: Egg shell calcification in silicosis and PMF
Differentials:
1. pulmonary talc
2. Granulomatosis
3. Sarcoidosis
4. lung cancer:
What next:
HRCT chest
Pulmonary function tests
Lung biopsy

159. • Egg shell calcification in mediastinum and
thoraxSilicosisLymphomaSchelodermaAmyloidosisCoal workers
pnemoconiosis

161. Hypersenistivity pmeumonitis
• 1st 2nd image multiple well defined centrinodular nodular opacity
with GGH
• 3rd image it becomes mosaic attenuation,some of having air trapping
looks black and some hvnt airtrapping and looks white giving heed
cheese appearance
• 4th image honeycombing,traction bronchiectasis, reticulations and
apico basilar gradient ..suggestive of UIP?
• So the story strts frm idiopathic allergic reaction termed extrinsic
allergic alveolitis/hypersensitivity pnemonitis and progress towards
UIP So the HSP is leading cause of UIP

163. scleroderma
Study: CXR FRONTAL PROJECTION
Description: showing diffuse reticular changes bilaterally. No superimposed consolidation or cavitation or
calcification. CP angles are normal. Dx scleroderma next. Blood test, antinuclear antibodies level, CT chest
Ddx. Usual interstitial pneumonia, pulmonary fibrosis?HRCT axial view showing pulmonary fibrosis
bilaterally particularly in the bases. Honey combing, intralobular septal thickening and traction bronchietasis
are also seen. Esophagus appear dilated and air filled. No pleural effusion.
Diagnosis: scleroderma
CRESTC
Calcinosis
R raynaud phenomenon
E esophageal dismotality.
S sclerodactyly
T telangectasia
Differentials:
What next:

164. • Xray chest frontal projection,
• HRCT chest axial view
• Bilateral diffuse reticular interstitial pattern more marked in lower
lobes.No cardiac abnormality seen .Bilateral CP angles clear. CT show
diffuse honey combing with interstitial fibrosis more marked in
subpleural region.
• DiagnosisUIP
• D/D NSIP, Cronic hypersensitivity pneumonia, systemic sclerosis

166. Eosinophilic granuloma and LCH
Study:Xray chest frontal projection,Xray AP Thoracic Vertebrae
Description: Bilateral diffuse reitulonodular shadowing more in mid
and upper zone,multiple thin wall cysts.No cardiac abnormality seen
.Bilateral CP angles clear.Vertebrae plana, multiple bevelled lytic
lesion in skull
Diagnosis: skullDiagnosis LCH( in skeleton called eosinophillic
granuloma)
Differentials: LAM,sarcodosis,millary tb,LIP
What next:

168. LCH and LAM features
CH HRCT chest axial shows thin walled cysts scatterd randomly
throughout bilateral lungs more in right lower lobe,few scatterd
solid nodules seen .HRCt chest axialLAM occur in women there are
multiple thin walled cysts uniformly distributed with minimal septal
thickening and right pneumothorax

170. • LCH randomly distributed cyst occur in children, young age,adult
strong history of smoking,costophrenic sparing LAM uniformly
distributed cysts occur in womenLIPsmooth small cysts,ground glass
attenuation

172. Alveolar microlithiasis
Study: x ray chest frontal projection,
Description: Enhanced CT axial Sand like calcification distributed through out
lung,black pleura sign,crazy paving pattern.No cardiac abnormality seen
.Bilateral CP angles clear.Diagnosis alveolar micrlithasis
Diagnosis: Alveolar microlithiasis
Differentials:
1. silicosis
2. Pulmonary baritosis
Association testicular microlithiasis
What next: biopsy pet ct,scrotal scan

175. CATHETERS & TUBES

180. Partial anomalous pulmonary venous return

182. Congenital lobar emphysema
Study:CT chest axial images
Description: There is paucityof pulmonary vessels with markd transradiancy
involving the left upper lobe with no mediastinal shift.right lung appears
unremarkable.no synchoronous lucency noted in right lung.hilum appears
Diagnosis: Congenital lobar emphysema
Differentials:
1. Mcleod’s synd
2. pneumatocele
3. large bulla
4. pulmonary atresia.
What next: mild cases of CLE follow upsevere cases lobectomy

185. CCAM
Study: CXR frontal projection
Description: and CT chest axial imageA large well defined cystic
structure is seen in right lower lobe with adjacent smaller cavitations.
Surrounding lung shows pneumonic changes.leftt lung appears
unremarkable.
Diagnosis: CCAM type II
Differentials:
1. congenital diaphargmatic hernia
2. bronchogenic cystpulmonary sequestration
What next:

187. AVM and Osler weber rendu syndrome
Study: CXR frontal projection and MDCT cornal images of pulmonary
angiogramon
Description: a well defined rounded opacity is seen in right lower lobe.
Surrounding lung is normal.nonsynchironous lesion seen in left lung.leftt lung
appears unremarkable.pulmonary angiogram shows a tubular serpenginous
structure arising from the right hilum and extending upto peripheral right lower
zone and draining into systemic veins.no evidence of any adjacent hemorrhge.
Diagnosis: AVM and Osler weber rendu syndrome
Differentials:
1. pulmonary varices
2. bronchocele
What next:

189. ARDS vs. TTN
CXR frontal projection neonate
LUng volume reduced.NG tube and ETT seen in place. Confluent air
shadowing is noted. THere is GG haze obscuring the cardiac
borders.CP angles clear. BOnes unremarkable.diagnosis.RDS
Diagnosis:TTN
treatment. exogenous surfactant therapy oxygen supplement

190. • CXR frontal projection
• Neonate lungs appear hyperinflated with increased intercostal space
distance.perihilar streakiness seen. CP angles clear. BOnes
unremarkable.
• Diagnosis.TTN
• D/D :
• RDS
• Meconium aspiration

191. CASES DISCLOSED
• 3rd Slide  Liver abscess, pneumoperitoneum
• 4th Slide  Hidden areas on chest X-ray
• 5th Slide  Posterior mediastinal masses
• 6th Slide  Bilateral hilar lymphadenopathy
• 7th Slide  Sarcoidosis (X-ray)
• 8th Slide  Sarcoidosis (CT)
• 9th Slide  Sarcoidosis (Nuclear)
• 10th Slide  Lung collapse (right upper and left upper)
• 11th Slide  Right middle lobe collapse
• 12th Slide  Kerley B lines
• 13th Slide  Solitary vs. multiple pulmonary nodules
• 14th Slide Solitary vs. multiple cavitatory lesions
• 15th Slide  Tension pneumothorax
• 16th Slide  Poland and Macleod's syndrome
• 17th Slide  Hamartoma
• 18th Slide  Mesothelioma
• 19th Slide  Neuroenteric cyst

192. CASES DISCLOSED
• 20th Slide  Pulmonary thromboembolism
• 21st Slide  VQ scan of pulmonary thromboembolism
• 22nd Slide  Pectus excavatum
• 23rd Slide  Mediastinal masses
• 24th Slide  Esophageal abscess and mediastinal lipomatosis
• 25th Slide  Pneumomediastinum, pneumopericardium and mediastinal hematoma
• 26th Slide  Mediastinal fibrosis
• 27th Slide  Atypical thymoma
• 28th Slide  Anterior mediastinal teratodermoid
• 29th Slide  Cystic hygroma
• 30th Slide  Epicardial fat pad
• 31st Slide  Morgagni hernia
• 32nd Slide  Achalasia
• 33rd Slide  Gastric herniation
• 34th Slide  Bronchogenic and neuroenteric cyst
• 35th Slide  Mediastinal lymphoma
• 36th Slide  Aortic aneurysm

193. CASES DISCLOSED
• 37th Slide  Aortic dissection
• 38th Slide  Debakey and Stanford classification
• 39th Slide  Posterior mediastinal mass
• 40th Slide  Paravertebral abscess
• 41st Slide  Extramedullary hematopoiesis
• 42nd Slide  Pleural effusion vs. empyema
• 43rd Slide  Bronchopleural fistula
• 44th Slide  Pulmonary asbestosis
• 45th Slide  Hypertrophic pulmonary osteoarthropathy
• 46th Slide  Lung tumors classification
• 47th Slide  Cavitating tumor and right upper lobe collapse (Golden S sign)
• 48th Slide  Lymphangitic carcinomatosis
• 49th Slide  Pulmonary bronchocele
• 50th Slide  Pancoast tumor
• 51st Slide  Varicella infection
• 52nd Slide  Round pneumonia
• 53rd Slide  Lipoid pneumonia

194. CASES DISCLOSED
• 54th Slide  Aspiration pneumonia
• 55th Slide  Peripheral opacities (Loffler's syndrome)
• 56th Slide  Hydatid disease
• 57th Slide  Hydatid signs
• 58th Slide  Kartagners syndrome and intralobar sequestrations
• 59th Slide  Mycetoma in TB
• 60th Slide  Tracheoesophageal fistula
• 61st Slide  Croup vs. epiglottitis
• 62nd Slide  Bronchial atresia
• 63rd Slide  Egg shell calcification in silicosis and PMF
• 64th Slide  Hypersensitivity pneumonitis
• 65th Slide  Scleroderma
• 66th Slide  Usual interstitial pneumonia
• 67th Slide  Eosinophilic granuloma and LCH
• 68th Slide  LCH and LAM features
• 69th Slide  LCH vs. LAM vs. LIP
• 70th Slide  Alveolar microlithiasis

195. CASES DISCLOSED
• 71st Slide  Pulmonary alveolar proteinosis
• 72nd Slide  CVP, Swan Ganz and NG catheter
• 73rd Slide  Chest tube, pacemaker and aortic balloon catheter
• 74th Slide  Schimitar syndrome
• 75th Slide  Congenital lobar emphysema
• 76th Slide  CCAM
• 77th Slide  AVM and Osler weber rendu syndrome
• 78th Slide  ARDS vs. TTN