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Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 1 :

 
Question :

A 5 day old boy with respiratory distress.
What is the diagnosis?
Answer :
 The medial pneumothorax, left

       Pneumothorax on chest radiograph is usually seen as air density lateral to or above the displaced lung. However, in neonates and infants who are maintained in supine position, air in pleural space is preferably anteriorly and medially located between the medial surface of the lung and the anterior mediastinum.

       Chest radiograph in supine position will show a dark band of air between the lung and mediastinum, the “sharp mediastinum” sign in medial pneumothorax. If there is large amount of the pneumothorax, contralateral mediastinal shift will be seen.

       Intercostal drainage for this type of pneumothorax should be performed with directing the tip of pleural tube anteriorly.
 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 2 :

 
Question :

Chest radiograph of 2 month old boy with hepatomegaly. What is the diagnosis?

Answer :
 Mediastinal neuroblastoma

       Mediastinal mass that shows rib erosion or intercostal space widening must be located in posterior mediastinum. When calcifications within the posterior mediastinal mass in pediatric patients are identified, the diagnosis of thoracic neuroblastoma could be made.

       CT or MRI is recommended for defining local extension of the tumor, particular into the spinal canal.In this infant, hepatomegaly is from liver metastasis
 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 3 :

 
Question :

What is the diagnosis?
Answer :
 Tracheal bronchus

       Tracheal bronchus arises from trachea (or main bronchus), usually from the right lateral wall and supplies the entire upper lobe or only its apical segment. Pigs have this type of bronchus, so the other name of tracheal bronchus is “bronchus suis”.

       Patients having tracheal bronchus are usually asymptomatic. However, few of them have narrowing tracheal bronchus with persistent or recurrent upper lobe pneumonia or air trapping, which have been reported.

 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 4 :

 
Question :

Chest radiograph of a 3 month boy. What is the diagnosis?

Answer :
 Congenital cystic adenomatoid malformation (CCAM)
       Finding of focal hyperlucent area of the lung containing a few large lung cysts is the most common manifestation of CCAM (70% of the cases, type 1). The other two types are those of numerous small cysts, and the innumerable microcysts. The latter one may show solid lesion or opacity rather than pulmonary hyperlucency on chest X-ray

       In this case, CCAM has to be differentiated with diaphragmatic hernia. The normal position of the stomach, normal bowel gas pattern, normal position of left hepatic lobe, and intact diaphragm (but it is depressed and inverted) make the diagnosis of diaphragmatic hernia unlikely.

       When confronting with cystic lesion in the thorax, we have to think about the possibility of either congenital lesion or acquired lesion. The congenital cystic lesions are congenital lung cyst, congenital cystic adenomatoid malformation, congenital lobar emphysema, pulmonary sequestration, and diaphragmatic hernia. The acquired cystic lesions could be lung abscess, pneumatocele, and cystic bronchiectasis.

 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 5 :

 
Question :

A 1 year old boy with choking, cough and wheezing. What is the diagnosis?

Answer :
 Foreign body aspiration in left main bronchus

       Foreign bodies may cause no airway obstruction, or complete obstruction, or partial obstruction with “one-way valve” mechanism. The latter pattern is our quiz case, unilateral large hyperlucent lung from air trapping is noted on chest radiograph, and this finding is better shown in expiratory chest film. Two lateral decubitus views can be used instead of inspiratory-expiratory films in uncooperative young children.

       Bronchoscope in this child revealed a half of peanut in his left main bronchus. CT is useful when foreign body is highly suspected, but initial chest X-ray or bronchoscope is negative. CT may reveal the presence and the location of foreign body, as well as reaction of the lung.

 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 6 :

 
Question :

A 5 year old girl with fever, cough, and dyspnea. What is the diagnosis?

Answer :
 Round pneumonia

       Pneumonia in children, particular those younger than 8 years – whose collateral pathway of air circulation is not well developed-, may appear as a round mass on chest radiograph. The most common infectious agent for round pneumonia is streptococcal pneumoniae.

       If the child has symptoms of pneumonia and a round opacity on chest radiograph, round pneumonia is suggested and there is no need to perform CT scan. However, follow-up chest X-ray several weeks after antibiotic treatment is suggested to exclude underlying mass.
.
 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 7 :

 
Question :

A 3 month old boy having hepatosplenomegaly. What is the diagnosis?

Answer :
 Langerhans cell histiocytosis

       Chest involvement in LCH could be lung parenchymal lesion, enlarged mediastinal lymph nodes, and osteolytic lesion of the bony thorax.

       For the pulmonary lesion, two forms have been described, depending on early or late stage. In early stage, the lung shows small nodules (1-5 mm diameter) some of which may cavitate. The fibrosis and cyst formation (each cyst is usually less than 1 cm size) are noted in later stage. Both forms are much better seen with CT scan. The chest radiograph findings consist of reticular, nodular, reticulonodular patterns, and honeycombing.
 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 8 :

 
Question :

An 8 month old boy. What is the diagnosis?

Answer :
 Endobronchial TB

       Differential diagnoses of air trapping are endobronchial lesions (foreign body, endobronchial TB, secretion), extrinsic lesions with pressure effect on bronchus (mediastinal mass, lymphnode enlargement, vascular ring), and bronchial wall abnormality itself (bronchomalacia). Evidence of hilar and mediastinal enlargement, as well as visualization of abnormal air column of bronchus may help in tailoring the differential diagnoses to TB and other mediastinal mass.

       Bronchoscope and/or CT chest give the correct answers in most cases.
 

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 9 :

 
Question :

An 8 year old girl falled from a tree. This is her chest radiograph. What is the diagnosis?

Answer :
 Scimitar syndrome

       Small (hypoplastic) right lung and ipsilateral anomalous pulmonary venous drainage to IVC - with Turkish sword (scimitar) appearance of the anomalous vein- seen from chest radiograph are diagnostic for scimitar syndrome (pulmonary venolobar syndrome).

       Forty percents of patients are asymptomatic, while the other 60% develop dyspnea on exertion in the 2nd or 3rd decade of life, depending to extension of the left to right shunt.

       When the diagnosis is suspected from chest X-ray, further investigation with CTA or MRA is recommended.

อ.นพ.บันดาล ซื่อตรง
ภาควิชากุมารเวชศาสตร์
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี

Case 10 :

ผู้ป่วยเด็กชายไทย อายุ 10 ปี มาด้วยอาการมือปากเขียวคล้ำามา 2 ปี ไม่ไอ ไม่หอบ เหนื่อยง่ายเล็กน้อย เคยไปตรวจเลือดที่โรงพยาบาล แพทย์บอกว่าเลือดข้น แรกเกิดแข็งแรงดี ไม่เคยเจ็บป่วยจนต้องนอนโรงพยาบาล...
 
ดาวน์โหลดรายละเอียด

Case 11 :

ผู้ป่วยเด็กหญิงไทย อายุ 20 วัน มาด้วยอาการหายใจลําบากและเขียวมากขึ้นเวลาร้อง 12 ชั่วโมงก่อนมา โรงพยาบาล ไมีมีประวัติไข้ ไอ น้ำมูกร่วมด้วย...
 
ดาวน์โหลดรายละเอียด

อ.พญ.สุชาดา ศรีทิพยวรรณ
ภาควิชากุมารเวชศาสตร์
คณะแพทยศาสตร์จุฬาลงกรณ์มหาวิทยาลัย

Case 12 :

ผู้ป่วยเด็กชายไทยอายุ 2 เดือน admit ที่โรงพยาบาลจุฬาฯครั้งแรกด้วยอาการไอ น้ำามูกใส หายใจหอบ ประวัติอดีต คลอดครบกําหนด โดยวิธี vacuum extraction มารดาบอกว่าผู้ป่วยหายใจแรงตั้งแต่แรกเกิด ไม่เคยต้องนอนโรงพยาบาล เคยพาไปพบแพทย์ แพทย์บอกว่าปกติ ไม่เคยได้รับการ x-ray มาก่อน...
 
ดาวน์โหลดรายละเอียด

น.พ สรศักดิ์ โล่ห์จินดารัตน์
หน่วยระบบหายใจและไอซียู
สถาบันสุขภาพเด็กแห่งชาติมหาราชินี

Case 13 :

ผู้ป่วยเด็กหญิงไทย อายุ 4 เดือน มีอาการไอ เสมหะ อาเจียน เป็นมา 3 สัปดาห์ มีไข้ต่ำ เป็นบางวัน ประวัติการคลอดปกติดี น้ำาหนักแรกเกิด 3 kg....
 
ดาวน์โหลดรายละเอียด

รศ.พญ.จิตลัดดา ดีโรจนวงศ์
หน่วยโรคระบบหายใจและเวชบําบัดวิกฤต
ภาควิชากุมารเวชศาสตร์ คณะแพทยศาสตร์ จุฬาลงกรณ์มหาวิทยาลัย

Case 14 :

ผู้ป่วยเด็กอายุ 7 ปี มาด้วยอาการไข้สูง ไอ เจ็บหน้าอกด้านขวามา 2 วัน ประวัติอดีต แข็งแรงดีมาตลอด ไม่เคยเจ็บป่วยร้ายแรงจนต้องนอนโรงพยาบาล.... >
 
ดาวน์โหลดรายละเอียด

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 15 :

 
Question :

A 2 years old girl presented with recurrent pneumonia. Physical examination revealed wheezing and secretory sound from both lungs.

  The imaging is lateral view of esophagogram.
What is the diagnosis?
Answer :

There is soft tissue density lesion between esophagus and trachea (arrows),
The lesion causes indentation on posterior wall of trachea and anterior wall of the esophagus
 
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ผ.ศ.พญ.อาภัสสร วัฒนาศรมศิริ
Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 16 :

CXR ที่น่าสนใจนี้เป็นคำเฉลยของคำถามใน webboard15"
Figure 2:

Lateral neck
Findings: Markedly enlarged adenoids causes very narrowing nasopharyngeal airway. Also moderately enlarged palatine tonsils.
Impression :

Adenotonsillar hypertrophy
 



อ.นพ.ธีรเดช คุปตานนท์

Case 17 :

Azygos lobe
เป็น accessory lobe พบได้ที่ปอดขวาส่วนบน ที่เกิดจาก azygos vein พาดผ่านบนปอด ลักษณะทาง x-ray จะเห็นเป็นรูป tear drop ที่บริเวณ T5 ถึง right upper midline ไม่ต้องรักษาเพิ่มเติมใดๆ



ผ.ศ.พญ.อาภัสสร วัฒนาศรมศิริ
Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 18 :

 
Figure 3:

expiratory chest (a) and inspiratory chest (b) and radiograph

Findings:

(a) Expiratory chest with posterior aspect of right 7th rib being above dome of right hemidiaphragm, narrowing intercostals spaces, buckling trachea, and sunken cardiac apex within the left hemidiaphragm. Much tracheal buckling that one may suspicious of left paratracheal mass. No definite pulmonary infiltration
 

(b) Good lung inflation with posterior aspect of right 9th rib being above dome of right hemidiaphragm, widening intercostal spaces, and straight trachea. Normal other findings but thickening of perihilar lung markings, probable from bronchitis, or asthma.

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 19 :

 
Film quiz:

A 8 year-old boy with fever, weight loss, and anemia.

Findings:

- Superior mediastinal mass with bilateral convex bulging of the mediastinum, more on the right side. No calcification within the lesion.
- From lateral view, mildly increased opacity posterosuperiorly behind trachea.
- No tracheal shift in both PA and lateral views.
- Widening right and left 2nd-3rd intercostals spaces at posterior aspect, as compare to intercostals spaces at other levels.
- Normal heart, lungs, and pulmonary vasculature.
Opinion:

- Widening of intercostal space posteriorly in this case of mediastinal mass suggests the mass to be in posterior location, likely paraspinal mass with mass effect on the adjacent ribs.
- Differential diagnosis of posterior mediastinal mass in a child includes tumors of sympathetic ganglion origin (ganglioneuroma, ganglioneuroblastoma, neuroblastoma), nerve sheath tumor (neurofibroma, schwannoma), enteric or neurenteric cyst, lymphadenopathy.
- Further imaging investigation is MRI or CT.

MRI is preferred to CT in case of posterior mediastinal mass, because of better demonstration of intraspinal tumor extension which is common in neurogenic tumor.

Histologic diagnosis : Neuroblastoma
His bone survey shows multiple bone metastases.

Figure 1.1 and 1.2 : Chest PA(a) and left lateral (b) views

Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 20 :

 
Film quiz :

A 12 year old girl with incidental mass detected from chest radiograph.

Findings:

- A large lobulated mass (9.5x6 cm) at right lower hemithorax, silhouette with posterior two-thirds of right diaphragm, containing a dense oval calcification inferiorly.
- No pleural effusion.
- No adjacent or other infiltration.
- Normal cardiac size and normal pulmonary vasculature
- No evidence of hilar or mediastinal lymphadenopathy.
- Normal bony structure.
Opinion:

1) The mass could be originated from the lung, posterior mediastinum, and pleura.
2) Pleural mass is unlikely because it is almost always associated with pleural effusion.
3) For the lung mass with calcification, the differential diagnosis includes inflammatory pseudotumor, hamartoma, granuloma, pleuropulmonary blastoma, metastasis of some malignancies.
4) For the mediastinal mass with calcification, the differential diagnosis includes tumors of sympathetic ganglion origin (ganglioneuroma, ganglioneuroblastoma, and neuroblastoma).

 

Figure 1.3:

Coronal plane reformation of arterial-phased CT chest at level of descending aorta
- Arterial phased CT chest is performed to detect origin of arterial supply to the mass. The study reveals right descending pulmonary artery and right inferior phrenic artery as two feeders. We may suggest the lesion starts from the lung, then increases size until attaching or invading mediastinum and it later gains the second artery supply from systemic circulation. On the contrary, mediastinal mass even very large size, will not gain blood supply from pulmonary circulation.
Opinion:

Final diagnosis from histology:  Plasma cell granuloma

  Inflammatory pulmonary pseudotumor, plasma cell granuloma, xanthogranuloma, and fibrous xanthoma are terms used to describe reactive myofibroblastic inflammatory process seen in children. It accounts for about half of benign lung tumors of childhood. The lesion is usually clinically silent.

          Radiographs typically show a variably sized rounded or lobulated pulmonary parenchymal mass. Many of these lesions are more than 4 cm in diameter when detected. Calcification is common, often amorphous and scattered.

(Ref. Kird DR. Practical Pediatric Imaging Diagnosis Radiology of Infants and Children, 3rd ed. 1998; p 795)

ผศ.พญ.อาภัสสร  วัฒนาศรมศิริ
Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 21 :

 
Film quiz :

Caseเด็กอายุ7เดือน   normal labour คลอดท่าbreech, term AGA with mild birth asphyxia.BW 3,190 gm มีภาวะ meconium aspiration ให้ ATB เป็น ampicillin + gentamicin (5 วัน), clafloran + amikin (5 วัน) imipenam+amikin (14 วัน) on ET tube with ventilator 4 วัน

Findings:

CXR finding
Blurring of the images decrease image quality. This is rather from motion during using digital camera rather than suboptimal imaging technique.
 - Cystic lesions are noted in left lower chest, likely from high position of bowel loops. There is contralateral mediastinal shift, which is more exaggerate by mild rotatation of patient slightly to the right in AP view.
- The left hemidiaphragm is not well seen in AP view, probable from blurring of the image or diaphragmatic defect!, but from left lateral view, the left hemidiaphragm seems to be intact and much elevated.

- So the findings are suggestive of eventration (membranous thinning) of the left hemidiaphragm, rather than diaphragmatic hernia or cystic lung disease.
 
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ผศ.พญ.อาภัสสร  วัฒนาศรมศิริ
Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University
Case 22 :

2- There is a mass-like lesion with mildly lobulated contour in right upper lung in PA view. In lateral view 2.1, it is suggested to be posteriorly located, possible in superior segment of right lower lobe.  No pleural effusion or adenopathy is seen.

- With history of acute high fever, finding is likely from round pneumonia.
But in other clinical settings, lung mass should be considered, such as metastasis, pleuropulmonary blastoma, hamartoma, intrapulmonary bronchogenic cyst.

- Because of its peripheral location in posterior aspect, ultrasound may have a role in differentiation between pneumonia and mass. Follow up chest radiograph will also help in confirming the diagnosis.

2.2 pictures are F/u CXR after treatment with ATB and supportive treatment
Figure 2
Figure 2.1
Figure 2.2
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พ.ท.หญิง พญ.สุพิชญา จึงจิตรักษ์
โรงพยาบาลพระมงกุฎเกล้า
Case 23 :

Chest X ray: Right lung collapse with shift of mediastinal structures and trachea toward the affected side, diminished pulmonary vascularity on involved side Herniation of left lung across the mediastinum (compensatory) Increase radiolucency in the left hemithorax
Elevated right hemidiaphragm, depressed contralateral diaphragm

CT chest:: Complete absence of lung tissue on the right side with ipsilateral mediastinal shift Left lung was seen herniating to the opposite side due to compensatory hypertrophy Right pulmonary artery and bronchus were absent Pulmonary agenesis
Complete absence of a lung, it differs from aphasia in the absence of a bronchial stump. Bilateral pulmonary agenesis is incompatible with life, presenting as severe respiratory distress and failure Unilateral agenesis may have few symptoms and non-specific
findings. Right lung agenesis has higher morbidity and mortality than left lung agenesis: aorta can compress trachea or central airway compression Associate with other congenital anomalies; such as VACTERL sequence, ipsilateral facial, skeletal, cardiac malformation
Investigation: CT chest is diagnosis, bronchoscopy Conservative treatment is recommended Compensatory growth of remaining lung allows for improved gas exchange, but mediastinal shift can lead to scoliosis and airway compression

 
 
Chest X
CT chest
  
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ผศ.พญ.อาภัสสร วัฒนาศรมศิริ
Panruethai Trinavarat,M.D. Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 24 :

ผู้ป่วยเด็กหญิง อายุ 11 ปี เคยหอบหลายครั้งตอนเด็ก ไม่หอบมาหลายปี ครั้งนี้ไอมีเสมหะ น้ำมูก และเหนื่อยมา 2 วัน ก่อนมาโรงพยาบาล ไม่ได้พาไปพบแพทย์ วันที่พามาสังเกตว่าไอเหนื่อยมาก ไม่มีประวัติ choking
           PE : marked congest nasal mucosa with mucoid discharge
                 SpO2 room air 93%, subcostal retraction
                 Breath sound of Lt. lung

CHEST: PA upright In both films, there is decreased left lung volume with mediastinal shift to the left and elevation of left hemidiaphragm, more in image B. In A, the left retrocardaic area is opaque and border of the left hemidiaphragm is poorly seen; possible from consolidation or atelectasis. With evidence of volume loss, LLL atelectasis is favorable, even the typical sharp lateral demarcation line is not seen. In B, the upper part of left cardiac border and pulmonary trunk are obliterated with opacity of left upper lung, and evidence of volume loss of the left lung; indicating LUL atelectasis.

 
 
 
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ผศ.พญ.อาภัสสร วัฒนาศรมศิริ
Panruethai Trinavarat,M.D. Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 25 :

ผู้ป่วยมีไข้สูง ไอ หายใจเหนื่อย
           PE : subcostal retraction
                 Generalized exp. Wheezing, coarse crepitation
           CBC : Hct 37% WBC 8,300 PMN 59 L 28
                      Mycoplasma IgM

CHEST : PA, upright If the technician correctly put the marker (L) on patient’s left side, the patient should have situs inversus totalis. Cardiac size is normal. Mild perihilar and both lower lobe peribronchial opacities are seen. There is a small patchy opacity with sharp margin in left retrocardiac region, probable (sub)segmental atelectasis. If the patient has clinical suspicion of pneumonia, viral pneumonia is likely.

 
 
 
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ผศ.พญ.อาภัสสร วัฒนาศรมศิริ
Panruethai Trinavarat,M.D.
Assistant Professor.
Department of radiology, Faculty of medicine,
Chulalongkorn University

Case 26 :

 
 
     
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นพ.จรินทร์ แววพานิช
แพทย์ผู้ช่วยอาจารย์ หน่วยโรคระบบหายใจ ภาควิชากุมารเวชศาสตร์ รพ.รามาธิบดี

Case 27 :

Hx: เด็กชายไทยอายุ 2 ปี มีไข้ไอมีเสมหะมา 1 อาทิตย์ก่อนมาร.พ. ก่อนหน้านี้แข็งแรงดี ไปตรวจที่ร.พ.พบว่ามีความผิดปกติของ flim chest จึงส่งตัวมารักษาต่อ

PH: ปฏิเสธโรคประจำตัว ก่อนหน้านี้แข็งแรงดีตลอด ปฏิเสธ สัมผัสใกล้ชิดกับคนไอเรื้อรังหรือเป็นวัณโรค

PE: A Thai boy, good consciousness, mild pallor, no jaundice
HEENT: nose no discharge, pharynx and tonsil not injected
Lymph node: negative
Heart: normal
Lung: mild tachypnea, RR 36/min, good air entry, clear and equal breath sound
Abd: soft, no mass, liver and spleen not enlarge
Ext: no rash
 
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CCAM

Case 28 :

ผู้ป่วย อายุ 2 เดือน refer จาก รพ.อ่างทองด้วยเรื่อง ไอ หายใจเร็ว...
 

พบ pneumatocele, poor wt gain 
ตรวจร่างกาย   Lt 51, BW 2.3
Lung: rhonchi
CBC    6/6/50 Hct 32.4, Hb 10.9, WBC 10700 (N:7, LL 77, E7, M5, ATL 4) plt 548,000
HRCT = one large cyst and cluster ที่ multiple small cysts at Lt lower lung
UGIS: mod to severe GER, gastric wash for AFB XIII = negative
การวินิจฉัย LBW, lung cyst LLL, moderate to severe GER
การรักษาที่สำคัญ        Ceftazidime + amilkin x 14 days (Rx sepsis)
Ranidine ,cisapride
การดำเนินโรค หลัง antibiotic x 14 d repeat H/C = NG
F/U CVT 2 wk
 

Chest : AP supine (a1)
- A group of cysts of variable sizes at medial side of left lower lobe. The largest cyst is above 2 cm size.
- Mildly increased volume of the left lung with flattening of left hemidiaphragm.
Intact diaphragm.
Chest : Left lateral (a2)
- Posterior location of the cysts with anterior displacement of pulmonary vessels in lower lung.
DDX: CCAM type 1, and pulmonary sequestration.
CT chest (a3): Axial plane of lower chest, using lung window.
- A group of small cysts in posterior basal segment of left lower lobe.
(Other images (not shown) using mediastinal window do not show systemic artery supply to this area of the lung.)
DX: CCAM type 1

 

Pulmonary sequestration

Case 29 :

ผู้ป่วย เพศ หญิง อายุ 12 ปี จ.กรุงเทพฯ

 

admit ที่ รพ.นพรัตน์ราชธานี เมื่อ 7 กรกฎาคม 2547 ด้วยเรื่อง ไข้ ไอ เสมหะเขียว 1 wk
PE: BW 47 kg, p 100/min, RR 25/min, BT 36.2OC, decrease breath sound RLL
CXR: Imp: Lung abscess
Past Hx:  ก.พ. 47 admit ด้วยเรื่อง Rt pleural effusion Rx ceftriaxone, Erythro 10days
                   มี.ค. 48 Dx pneumonia ไม่มี effusion  
Hb10.5  Hct   34.6%    WBC 22,330   N 87 L 7 M 6 Plt 473,000    
CXR: air  fluid level RLL
Sputum AFB mg x 3D, TT 12 mm
CT chest:  pulmonary sequestration

 
 
 

Chest : PA upright (b1)
- Cystic lesion with air-fluid level at medial part of right lower lung, neither silhouette with right heart border or the diaphragm. Lower extension of the opacity is to lung base; cannot tell whether there are more than one cysts or there is also solid component.
Chest: Right lateral (b2)
- Posterior location of the lesion with air-fluid level; broad pleural-based lesion.
DDX: Pulmonary cystic lesion: CCAM, pulmonary sequestration
Pleural lesion : loculated pleural fluid, post tapping (so the lesion contains air)

CTA of the thoracic aorta
(b3): Post IV contrast, axial plane at lung base, mediastinal window
- A branch from right lateral wall of thoracoabdominal aorta feeds the pulmonary lesion in posterior segment of right lower lobe. The inferior solid-appearance portion of the pulmonary lesion with heterogeneous enhancement is noted.
(b4 and b5): Reformatted MIP (maximal intensity projection) image in mildly-oblique coronal plane.
- This view better demonstrates the arterial branch from thoracoabdominal aorta about level of diaphragm to supply complex solid-cystic lesion in right lower lobe, and venous drainage into right lower pulmonary vein.
DX: Intralobar pulmonary sequestration

 

2nd Pulmonary sequestration

Case 30 :

ผู้ป่วย อายุ 9 เดือน ไข้ ไอ หอบ2 วัน ไข้สูงขี้น 1 วัน
 

PE: BW 9.3 kg , BT 38.5OC, RR 45/min, dyspnea
Lung: rhonchi, crepitation Rt > Lt lung
 
 
 

Chest: AP, supine
- Pulmonary consolidation at medial aspect of right lower lung, not silhouette with right heart border; suggested to be in posterior basal segment, and probable also involve superior segment, of right lower lobe.
Impression: Pneumonia in right lower lobe, bacterial pattern.

 

Bronchogenic cyst

Case 31 :

เด็กหญิงไทยใหญ่อายุ 8 เดือน ภูมิลำเนา อ.แม่ลาน้อย จ.เชียงใหม่ ไข้ ไอหายใจเหนื่อย  3 วันก่อนมารพ...

ดาวน์โหลดรายละเอียด

 

Chest: AP supine (d1)
- Bilateral pulmonary hyperinflation.
- Minimal infiltration in lateral aspect of left lung base.
- Mildly convex bulging both right and left sides of superior mediastinum, more on the right, with prominent shift of NG tube to the right
IMPRESSION ; Superior mediastinal mass, suggested to be posterior compartment.
CT chest: post IV contrast
(d2) A series of 3 reformatted coronal plane at level of trachea and behind.
- A large oval shaped non-enhanced hypodense mass with smooth and sharp margins in superior mediastinum behind the trachea.
(d3) A series of 4 axial  plane at level of aortic arch and above.
- Wide separation of trachea and esophagus by the mediastinal hypodense mass.
- Esophagus with indwelling NG is noted at right paraspinal area.
IMPRESSION; Mediastinal mass, suggestive to be uniloculated cystic lesion, locates between middle and posterior mediastinum.
DDX: Bronchogenic cyst VS enteric cyst.
Cystic hygroma may also be in DDX but more commonly cystic hygroma is multiloculated.
 
 

Lung abscess

Case 32 :

เด็กหญิงไทยใหญ่อายุ 8 เดือน ภูมิลำเนา อ.แม่ลาน้อย จ.เชียงใหม่ ไข้ ไอหายใจเหนื่อย  3 วันก่อนมารพ...
3 เดือนก่อนมาโรงพยาบาล ผู้ป่วยเริ่มมีอาการไข้เป็น ๆ หาย ๆ ....
ดาวน์โหลดรายละเอียด


 

Chest: AP supine (e1) : 26/3/51
- Mass like consolidation in right upper and middle chest, crossing minor fissure which is mildly thickened.
Impression ; Pneumonia of alveolar pattern in superior segment of right lower lobe.
Minimal right pleural effusion.

Chest: AP supine (e2) : 02/6/51
- Large consolidated area in lower half of right lung with remained small aerated lung close to right heart borer.
Impression ; Pneumonia of alveolar pattern in right lower lobe and right middle lobe.

CT chest: a series of 6 axial images in lower half of the chest (e3) : 05/6/51
- Multiple discrete and coalesce hypodense lesions, some with enhanced walls, within the areas of pulmonary consolidation in right middle and right lower lobes.
- Minimal free right pleural effusion seen in dependent portion of the chest in lower images.
Impression : Multiple pulmonary abscesses in lobar consolidation of right middle and lower lobes.

 
Pneumothorax
Case 33 : ด.ญ. อายุ 1 วัน           

 

มารดา G2P1 GA 36 wk คลอด C/S due to Previous C/S  with oligohydramnios
APGAR score 7, 8 BW 2,280 gm
อายุ 4 hr. ขณะดูดนม มีอาการปากคล้ำ  SpO2 87% ให้ Oxygen 3LPM, FiO2 0.28 , SpO2 -->94%
D2 RR 56-64/min  SpO2 ขณะหลับ 94-97% ขณะดูดนม 90-98% wean oxygen
D3 RR 54-60/min  SpO2drop 3 ครั้ง
Rx : Oxygen Box 5 LPM FiO2 1.0 x 1 วัน --> FU CXR resolved
 
 
 

Chest: AP supine
-Hyperlucent left hemithorax with medial displacement of visceral pleural line, deep left costophrenic sulcus (deep sulcus sign), and contralateral mediastinal shift.
-Normal thymic sail sign.
Dx: Left pneumothorax.
NB. Degree of mediastinal shift to the right could be more exaggerated in this image because the patient is mildly rotated to the right.
 
RUL Pneumonia (bacterial)
Case 34 : ด.ญ. อายุ 3 ปี           

 

ไข้ สูงหนาวสั่น ไอมาก 4-5 วัน ไอ เสมหะ ซึม ท้องอืด ไม่กินอะไร
PE  :    BT 40.3 C, RR 50/min. Suprasternal retraction, sunken eyeball
            Lung : no crepitation, no wheezing
            CBC; Hb 10.2, Hct. 31%, WBC 24,830 PMN 82%, Lym 6%, Mono 12%, Plt. 343,000
            Mycoplasma (IgM) titer : Negative
            Rx : Ceftriaxone 100 mg/kg/day x 4 days -> Cefdinir x 4 days (Fig. 2) &  F/U 1 mo (Fig. 3)
 
 

Chest: PA upright (g1)
- Homogeneously-dense patchy opacity is noted in right upper lobe with sharply defined linear inferior border which is likely to be elevated minor fissure.
Impression;     Patchy opacity with significant volume loss, suggestive of atelectasis.
Location of the lesion is at anterior segment of right upper lobe.
Whether or not alveolar pneumonia is a part of this opacity cannot be excluded.
Chest: PA upright (g2)
- Homogeneously-dense patchy opacity is noted in right upper lobe with sharply defined linear inferior border without elevation of minor fissure.
Impression: Without significant volume loss in the follow up film, pneumonia of alveolar pattern (favorable bacterial pneumonia) is considered
 

RUL (anterior segment) pneumonia
Case 35 : เด็กชายไทย อายุ 1 ปี ภูมิลำเนา จ. สมุทรปราการ           

 

CC ไข้สูง 3 วัน
PI 3 วันก่อนมารพ. ดื่มน้ำยาไฮยีน 1 คำ บิดาเอาน้ำล้างปากให้ 
     ต่อมาผู้ป่วยอาเจียน เป็นอาหารที่เพิ่งกินไป  หลังจากนั้นอาการปกติ พามาตรวจที่รพ. ตรวจร่างกายปกติ กลับบ้านมีไข้สูง จึงมาตรวจซ้ำ
P.E.A male infant, looking well, BT 39°C, RR 30/min
HEENT normal oral mucosa,
              mildly injected pharynx, tonsils2+
Chest&lungs clear
Px:

  • Ceftriaxone for 3 days then cefdinir until completion of 7 days
  • Follow-up: normal

 
 
 

Chest: AP supine
- Homogeneously-dense patchy opacity is noted in right upper lobe with sharply defined linear inferior border with mildly downward position of minor fissure.
Impression: Consolidation (alveolar infiltration) in anterior segment of right upper lobe; possible pneumonia (bacterial pattern), pneumonitis (according to history), or hemorrhage.
 

Loculated effusion
Case 36 : เด็กหญิงอาหรับ อายุ 3 ปี ภูมิลำเนา ประเทศ United Arab Emirates(UAE)....           


 
ดาวน์โหลดรายละเอียด
 
 

Chest: AP supine
- Homogeneously-dense patchy opacity is noted in right upper lobe with sharply defined linear inferior border with mildly downward position of minor fissure.
Impression: Consolidation (alveolar infiltration) in anterior segment of right upper lobe; possible pneumonia (bacterial pattern), pneumonitis (according to history), or hemorrhage.

Chest: PA, upright (i1); post treatment
- Much decreased size of the opacity in the right lung, with remained loculated pleural effusion (or pleural thickening) at lateral and posterior aspects of right lower hemithorax.

 

Dysfunctional swallowing,GER
Case 37 : เด็กชายอาหรับ อายุ 1ปี 10 เดือน ภูมิลำเนา ประเทศ United Arab Emirates(UAE)           

 

CC หายใจครืดคราด 3-4 เดือน
PI    Underlying disease: Hydrocephalus S/P VP shunt,
         Global developmental delay, recurrent pneumonia,
         3-4 เดือน ก่อนมารพ. หายใจครืดคราด เสมหะมาก ไม่มีไข้
        กินได้น้อย น้ำหนักไม่เพิ่ม ไม่ไอหรือสำลักขณะกิน
P.E.alert,  BW 7.3 kg, Ht 74 cm., BT 37.8°C, RR 40/min
Chest&lungs mild subcostal retraction, generalized coarse crepitations and expiratory wheezing both lungs
Neuro floppy,  Motor grade II/V, DTR 2+,
Management:
1.Aspiration pneumonia: Clindamycin, Cefipime/ Oxygen therapy/ Pulmicort, ventolin, chest rehabilitation
2.GERD and dysfunctional swallowing: NG tube feeding, lansoprazole, metoclopamide/ Occupational therapy/Gastrostomy and fundoplication

 
 

Barium swallowing: A spot film in AP view (j1)
- A streak of barium leaks into larynx and upper trachea.
- Unremarkable finding of esophagus with indwelling NG tube.
Impression; Tracheal aspiration during swallowing; suggestive of swallowing dysfunction.

GER scan: a series of images obtained during 11-20 minutes after feeding, 20 seconds per frame (j2)
- In frames number 117 and 119, the isotope is detected in the mouth, indicating high grade reflux. In some other frames, such as number 103 and 105, the isotope is also detected in the esophagus.
Impression: High grade gastroesophageal reflux up to the mouth

 

superior segment pneumonia-atelectasis
Case 38 : ผู้ป่วยอายุ 9 ปี แข็งแรงดี ไข้สูงมา 3 วัน ไปโรงพยาบาลได้ Amoxicillin + Roxithromycin ไม่ดีขึ้น....           


 
ดาวน์โหลดรายละเอียด
 

Chest: PA upright (k1)
- A triangular shape opacity is noted at middle part of right lung with its base towards the mediastinum but not silhouette with right heart border. Its upper margin is sharply defined in linear outline.
Impression; Suspecious of atelectasis of right middle lobe (from its shape and sharp linear upper margin); however, unusual for non-sillhouette with right border, probable a part of medial segment is spared from atelectasis.

Chest: PA upright (k2)
- Follow up film shows larger size of the triangular shape lesion with now sharp inferior margin. The minor fissure appears to be seen as at thick linear opacity superimposed on the lesion. Right heart border is still well seen.
Impression; Pulmonary atelectasis is possible in superior segment of right lower lobe, not in middle lobe as previously considered.

Chest: Right lateral (k3)
- Lateral view confirms triangular-shaped opacity in superior segment of right lower lobe, with sharp linear outline of major fissure which is downwards in position. Inferior margin of the atelectasis also has sharp linear margin.
Impression; Atelectasis of superior segment of right lower lobe.
 

Atelectasis from blood clot at RML,RLL
Case 39 : เด็กหญิงไทย อายุ 10 ปี 4 เดือน ภูมิลำเนา จ.สระบุรี....           


 
ดาวน์โหลดรายละเอียด
 
 
 

Chest: AP upright
- Homongenously dense opacity in right lower lung silhouette with right heart border and the whole right hemidiaphragm, hyperinflated right upper lobe, and mediastinal shift to the right.
Impression; A large area of pulmonary opacity with significant volume loss indicates atelectasis. From location and silhouette sign, atelectasis of right middle lobe and right lower lobe is considered. If there is any obstructing cause, it should be in intermediate bronchus.


LUL agenesis
Case 40 : ผู้ป่วยเด็กหญิงไทย อายุ 5 เดือน มีอาการไข้ ไอ หายใจหอบไปรักษาที่ รพ. รัฐ วินิจฉัยปอดบวม ให้ยาปฏิชีวนะ นอน รพ. 5 วัน           


3 วันก่อน มีอาการไข้ ไอ น้ำมูกใส หายใจครืดคราด หอบ
ตรวจร่างกาย –RR 40/min, T 37.5 oC  No cyanosis, Tachypnea
HEENT- pharynx mild injected. Nasal discharge clear
Heart normal s1s2 no murmur
Lung-  asymmetrical chest wall, transmitted sound, no wheezing, asymmetrical breathsound
CBC- Hb 10.3 g/dl, Hct 32.1%, Wbc 10,500/cumm. PMN 14% Lym 80 Mo 6 plt
Adequate
 

Chest: AP supine (m1)
- Small left lung volume.
- Small and mildly deformed left 3rd rib.
- Opacity in left side of superior mediastinum continued to upper one-fourth portion of left hemithorax with sharply-outlined inferior concave margin.
- Tracheal shift to the right, uncertained whether caused by left sided superior mediastinal lesion or suboptimal inspiration.
- Partially obscured border of left hemidiaphragm, and left cardiac border.
- Increased flow to right lung, and relatively decreased flow to left lung.
- Normal cardiac size.
Impression: Small left lung volume, probable from congenital or atelectasis.
Left sided superior mediastinal mass, uncertain whether it is true mass or thymus; further investigation with US or CT is recommended.
Asymmetrical pulmonary flow to right and left lungs.

CT chest: Volume rendering technique of the lung and tracheobronchial tree in frontal projection (m2)
- Small size of the left lung, and no atelectasis. Other images (not shown) revealed agenesis of left upper lobe.

CT chest: Axial plane at level of upper chest (m3)
- Aerated lung only in right upper lobe, but not in left upper chest. Mediastinal window (not shown) shows normal thymic tissue in left upper chest.

Retropharyngeal abscess
Case 41 :

เด็กชายไทยอายุ 4 เดือน  ภูมิลำเนา จ.เชียงราย....        


 
ดาวน์โหลดรายละเอียด
 

Lateral soft tissue of the neck (n1)
- Thickening retropharyngeal soft tissue from level of C1-C5, no air within the lesion.
- Obliteration of air in nasopharynx and oropharynx, and anterior displacement of hypopharynx.
- Straight (not extended) cervical spine.
Impression: Widening retropharyngeal soft tissue, probable retropharyngeal abscess.

CT neck: axial plane at level of oropharynx  (n2)
- Large lobulated area of fluid density with enhanced wall behind oropharynx (seen with indwelling NG tube) in midline location and extending right laterally behind right carotid space and sternocleidomastoid muscle to right lateral neck 
Impression; Retropharyngeal abscess with extension of the abscess to the right side of neck

CT neck: Reformatted image in coronal plane anterior to the cervical spine (n3)
- The image show supero-inferior extension of the abscess.

Foreign body aspiration
Case 42 : ผู้ป่วยเด็กหญิงไทย อายุ 5 เดือน มีอาการไข้ ไอ หายใจหอบไปรักษาที่ รพ. รัฐ วินิจฉัยปอดบวม ให้ยาปฏิชีวนะ นอน รพ. 5 วัน           


3 วันก่อน มีอาการไข้ ไอ น้ำมูกใส หายใจครืดคราด หอบ
ตรวจร่างกาย –RR 40/min, T 37.5 oC  No cyanosis, Tachypnea
HEENT- pharynx mild injected. Nasal discharge clear
Heart normal s1s2 no murmur
Lung-  asymmetrical chest wall, transmitted sound, no wheezing, asymmetrical breathsound
CBC- Hb 10.3 g/dl, Hct 32.1%, Wbc 10,500/cumm. PMN 14% Lym 80 Mo 6 plt
Adequate
 
 

Chest: AP, supine (o1)
- Asymetrical aeration of the lungs with large hyperlucent lung on the right, small and less lucent lung on the left, mediastinal shift to the left, and elevated left hemidiaphragm.
- No pneumothorax.
- No evidence of atelectsis.
Impression; Suggested air trapping in right lung. The obstructing cause should be at right main bronchus.

Chest: Right lateral decubitus (o2)
- The right lung is still hyperlucent, confirming air trapping.
 

Protocol Chest Xray Quiz
November 26, 2007 at Siriraj Hospital
Case 43 :

ผู้ป่วยเด็กหญิงไทย อายุ 15 ปี ภูมิลำเนา กทม      


อส.  ปรึกษาจาก โรงเรียนเนื่องจาก Routine CXR พบความผิดปกติ
ปป.   Case Dx Esophageal atresia type I S/P Esophagoesophagostomy since age 5-6 month Loss F/U 5 ปี
      มารดา สังเกตว่าตั้งแต่ เด็ก ๆ ผู้ป่วยมีอาการอาเจียนหลังกินอาหาร 2-3 วันต่ออาทิตย์ อาเจียน เป็นอาหารที่กินเข้าไปไม่เกิน 5-10 นาที นอกจากนี้ยังรู้สึกกลืนติด หลังจากกินอาหาร อาหารแข็งมีอาการมากกว่าอาหารเหลว จุก ๆ ใต้ลิ้นปี่ อาการอาเจียน ไม่สัมพันธ์กับท่าทางและเวลาไม่มีอาการคลื่นไส้ ไม่มีอาการปวดศีรษะ มารดาและผู้ป่วยคิดว่าไม่ได้ผิดปกติอะไร เนื่องจากหลังอาเจียนแล้ว ผู้ป่วยสามารถกลับไปกินอาหารได้ใหม่อีก อาการไม่ได้เป็นทุกครั้งที่กินอาหาร  ไม่มีเลือดปน ถ่ายอุจจาระปกติดีไม่แข็ง ไม่มีประวัติปวดท้องหรือ ท้องอืด  ผู้ป่วยรู้สึกว่าตัวเองดูตัวเล็ก ๆ  เมื่อเทียบกับเพื่อน ๆ
 
ดาวน์โหลดรายละเอียด