Chest Radiology Practice Questions

Q: The following CT chest shows:

A= Tree in Bud appearance, B= Ground glass pattern. ***Option A: A= Tree in Bud appearance, B= Ground glass pattern*** - Image A clearly shows the **"tree-in-bud" appearance**, characterized by small centrilobular nodules and branching linear opacities, which is indicative of filling of the small bronchioles with mucus, pus, or fluid and is commonly seen in infectious or inflammatory conditions. - Image B presents a **ground glass pattern**, which is a hazy increase in lung attenuation with preservation of bronchial and vascular margins, suggesting partial filling of air spaces or interstitial thickening without obscuring the underlying structures. *Option B: A= Crazy pavement pattern, B= Tree in bud appearance* - While "tree-in-bud" is correctly identified for image A, **image B does not show a "tree-in-bud" appearance**. - The "crazy paving pattern" refers to ground-glass opacities superimposed on thickened interlobular septa, which is not depicted in either image. *Option C: A= Mosaic perfusion pattern, B= Crazy pavement pattern* - Image A does not show a **mosaic perfusion pattern**, which is characterized by areas of varying attenuation due to regional differences in lung perfusion and air trapping. - Image B does not represent a **crazy pavement pattern**, as it lacks the clear visualization of thickened interlobular septa within the ground-glass opacities. *Option D: A= Bronchovascular nodular pattern, B= Ground Glass pattern* - While image B correctly identifies the **Ground Glass pattern**, the description for image A as a **bronchovascular nodular pattern** is too broad and imprecise. - The specific morphology in image A, with its branching and nodular opacities, is best described by the "tree-in-bud" appearance rather than a generic bronchovascular nodular pattern.

Q: A 6-month-old child is on Vancomycin for pneumonia for 2 days. He develops worsening of respiratory distress and $\mathrm{SpO}_{2}$ falls to $80 \%$. The CXR performed is shown below. What is the diagnosis?

Pneumothorax. ***Pneumothorax*** - The CXR shows marked hyperlucency and absent lung markings on the right side, along with a collapsed lung (seen as a dense shadow centrally), characteristic of a **pneumothorax**. - Worsening respiratory distress and a significant drop in saturation in a child with pneumonia receiving vancomycin (suggesting severe infection) could indicate a complication like a tension pneumothorax, which requires urgent intervention. *Lung abscess* - A lung abscess typically appears as a **cavitated lesion** with an air-fluid level, usually within the lung parenchyma. - While pneumonia can lead to abscess formation, the CXR image does not show a circumscribed cavitary lesion but rather a generalized collapse of lung tissue. *Empyema* - Empyema is characterized by **pus in the pleural space** and would typically manifest as a **pleural effusion** with a fluid level when erect, or diffuse opacification of the hemithorax. - The image distinctly shows a clear space with absent lung markings and a displaced lung, which is not consistent with merely fluid accumulation. *Segmental collapse* - **Segmental collapse (atelectasis)** would appear as an area of **increased density** within the lung itself, with crowding of vessels and bronchi, and possibly displacement of fissures and mediastinum towards the affected side. - This is distinct from the hyperlucent appearance of the right hemithorax and the clear displacement of the lung boundary seen in the image.

Q: What is the most likely diagnosis based on the chest radiographs shown below?

Segmental collapse. ***Segmental collapse*** - The frontal image shows a **wedge-shaped opacity** in the right upper lobe, and the lateral view reveals a **triangular area of increased density** consistent with collapsed lung tissue. - This pattern, particularly the triangular density on the lateral view and volume loss indicated by the position of the **minor fissure (white arrow)**, points towards segmental collapse. *Lung abscess* - A lung abscess typically presents as a **cavity with an air-fluid level**, which is not depicted in these images. - The lesion shown is mostly **solid and dense**, unlike the characteristic appearance of an abscess. *Lobar emphysema* - Lobar emphysema involves **overinflation of a lung lobe**, characterized by increased lucency and vascular attenuation, which is the opposite of the findings here. - There is no evidence of **air trapping** or **hyperinflation** in the images provided. *Bronchiectasis* - Bronchiectasis is characterized by **permanent abnormal dilation of the bronchi**, often seen as "tram tracks" or "ring" opacities on imaging. - The images do not show these specific findings; instead, they indicate a loss of lung volume.

Q: Which of the following is shown in the image below?

Westermark sign. ***Westermark sign*** - This image displays a **dilated pulmonary artery proximal to an area of oligemia**, specifically noted in the upper right lung field, as indicated by the arrow. This finding is characteristic of the **Westermark sign**, which is suggestive of a **pulmonary embolism**. - The Westermark sign represents **distal collapse of the pulmonary vasculature** due to a reduction in blood flow, making the lung parenchyma appear unusually lucent compared to adjacent normal lung fields. *Palla sign* - The Palla sign refers to a **dilated right descending pulmonary artery** (interlobar artery) on a chest X-ray. While it is also associated with pulmonary embolism, the image prominently shows oligemia, the defining feature of the Westermark sign, not solely an enlarged artery. - This sign indicates **increased pulmonary artery pressure** due to the embolus, but the key feature in the provided image is the reduced vascularity distally, not just the proximal vessel size. *Hampton hump* - A Hampton hump is a **wedge-shaped pleural-based opacity** with a rounded convex border facing the hilum. - It results from a **pulmonary infarction** due to a large pulmonary embolus and is not visible in this image. *Round pneumonia* - Round pneumonia is a **circular or oval-shaped consolidation** that is typically seen in children and appears as a mass-like lesion. - It is an infectious process with consolidation of lung tissue and does not involve vascular abnormalities like oligemia, which is clearly depicted in the image.

Q: An AIDS patient presents with respiratory distress. CXR shows:

Pneumocystis pneumonia. ***Pneumocystis pneumonia*** - The chest X-ray shows **diffuse bilateral interstitial infiltrates**, which is a classic presentation of *Pneumocystis jirovecii pneumonia (PJP)* in an AIDS patient. - PJP is an **opportunistic infection commonly seen in immunocompromised individuals**, especially those with AIDS and low CD4 counts, presenting with respiratory distress. *Miliary TB* - Miliary TB would typically show **numerous small (1-3 mm), well-defined, uniformly distributed nodular opacities**, resembling millet seeds, which are not clearly visible here. - While TB is common in AIDS, the diffuse interstitial pattern is less characteristic of miliary spread. *Streptococcal pneumonia* - *Streptococcal pneumonia* often presents as **lobar consolidation with air bronchograms**, typically affecting one or more lobes, rather than the diffuse interstitial pattern seen in the image. - While it can occur in AIDS patients, the radiographic features are not consistent with this diagnosis. *Lymphocytic interstitial Pneumonitis* - *Lymphocytic interstitial pneumonitis (LIP)* is more common in **pediatric AIDS patients** and often presents with more pronounced **nodular or cystic changes** and interstitial infiltrates, but the primary pattern for this acute presentation of respiratory distress as seen would be PJP. - While it is a differential consideration in AIDS patients with interstitial lung disease, the abrupt onset of respiratory distress with diffuse infiltrates points more strongly to an acute infection.

Q: A breast cancer patient presents with difficulty in breathing. CXR shows:

Cannonball metastasis. ***Cannonball metastasis*** - The chest X-ray shows multiple, well-defined, rounded opacities of varying sizes scattered throughout both lung fields, consistent with the characteristic appearance of **cannonball metastases**. - Given the patient's history of **breast cancer** and new onset **dyspnea**, pulmonary metastases are a very likely cause. *Pneumothorax* - A pneumothorax would appear as an area of translucency with absence of lung markings, often accompanied by a visible visceral pleural line and tracheal deviation in severe cases. This is not observed here; instead, the lungs are filled with multiple lesions. - The image does not show any signs of a collapsed lung, air in the pleural space, or shifted mediastinum. *Pulmonary artery hypertension* - Pulmonary artery hypertension on CXR might show **enlarged central pulmonary arteries** and pruning of peripheral vessels, or signs of right heart enlargement. - The predominant features in this image are numerous discrete nodules, not signs of vascular dilation or heart changes. *Interstitial lung disease* - Interstitial lung disease typically presents with a **reticular, nodular, or reticulonodular pattern**, often with reduced lung volumes and honeycombing in advanced stages. - The distinct, large, spherical lesions seen here are not characteristic of the diffuse, fine patterns associated with most interstitial lung diseases.

Q: An adult undergoes multiple FFP transfusions for excessive bleeding after cardiac surgery and develops respiratory distress. CXR done is shown below. What does it indicate?

TRALI. ***TRALI*** - The chest X-ray shows **bilateral pulmonary infiltrates** and **pulmonary edema** and the patient had multiple **FFP transfusions** followed by respiratory distress, which is highly suggestive of **Transfusion-Related Acute Lung Injury (TRALI)**. - TRALI is characterized by acute respiratory distress with **hypoxemia** occurring within 6 hours of transfusion, in the absence of other risk factors for **Acute Lung Injury (ALI)**. *Volume overloading of heart* - While fluid overload can cause pulmonary edema, the severity and rapid onset of distress after transfusion, coupled with the bilateral infiltrates, point more specifically to TRALI rather than isolated volume overload, especially in the context of FFP. - Cardiogenic pulmonary edema typically presents with **cardiomegaly** and signs of **heart failure**, which are not explicitly described or obviously seen as the primary cause in the given scenario and image. *Mendelson's syndrome* - Mendelson's syndrome, or **aspiration pneumonitis**, results from the inhalation of acidic gastric contents, leading to chemical pneumonitis. - This typically occurs in patients with impaired consciousness or those undergoing procedures that compromise airway protection, and there is no information in the vignette to suggest aspiration. *Pneumomediastinum* - Pneumomediastinum indicates the presence of **air in the mediastinum**, which would appear as radiolucent streaks outlining mediastinal structures on a CXR. - The image primarily shows diffuse bilateral infiltrates and pulmonary edema, rather than free air in the mediastinum.

Q: What is the diagnosis based on the CXR of a patient of cystic fibrosis shown below?

Bi-basilar fibrosis. ***Bi-basilar fibrosis*** - The image shows **increased reticular and nodular opacities**, particularly prominent in the **lower lung fields (basilar regions)**, consistent with pulmonary fibrosis. - In cystic fibrosis, chronic infection and inflammation lead to progressive lung damage, often manifesting as **bronchiectasis and interstitial fibrosis**, particularly in the lower lobes. *Round pneumonia with perihilar shadows* - **Round pneumonia** typically presents as a well-circumscribed, spherical opacity, often seen in children, which is not the predominant pattern here. - While there are opacities, they are more diffuse and reticular rather than forming distinct perihilar masses or round consolidations. *Hilar lymphadenopathy with coin shadows* - **Hilar lymphadenopathy** would appear as enlarged, prominent hilar regions, and while the hila are somewhat prominent, the primary finding is widespread parenchymal disease. - **Coin shadows** refer to solitary pulmonary nodules, which are not characteristic of the diffuse changes observed in this CXR. *Egg shell calcification* - **Eggshell calcification** is a specific pattern of calcified lymph nodes, typically found in conditions like silicosis or sarcoidosis, and is not visible in this image. - The CXR shows diffuse fibrotic changes rather than discrete calcifications.

Q: A 40-year-old male presents with sudden onset right-sided chest pain and breathlessness following a road traffic accident. On examination, breath sounds are diminished on the right side. The chest X-ray is shown below. What is the most likely diagnosis?

Right hydropneumothorax. ***Right hydropneumothorax*** - The X-ray image reveals an **air-fluid level** in the right pleural cavity, characterized by a straight, horizontal line between the air (darker above) and fluid (whiter below). This finding is pathognomonic for a hydropneumothorax. - The **collapsed or compressed lung** is also visible superior to the air-fluid level, further supporting the diagnosis of air and fluid coexisting in the pleural space. *Hydatid cyst right lung* - A hydatid cyst in the lung appears as a **well-defined, rounded opacity (solid mass)**, often with a "water lily" sign if ruptured, but it does not present with a distinct air-fluid level as seen here. - While hydatid cysts can rupture and produce air and fluid, the X-ray findings would typically show a more complex internal structure or a cyst within a cavity, not a simple air-fluid interface across the entire pleural space. *Right pleural effusion* - A pleural effusion would appear as a **homogeneous white (effaced) opacity** blunting the costophrenic angle and, in larger effusions, rising along the lateral chest wall (meniscus sign). - Crucially, a simple pleural effusion **does not show an air-fluid level**; the fluid density would fill the pleural space without an overlying visible air component. *Perforated abdominal viscus* - A perforated abdominal viscus would typically result in **free air under the diaphragm** on an upright chest X-ray (pneumoperitoneum). - While pneumoperitoneum presents as air, it is located below the diaphragm, *not* within the pleural cavity, and would not create an air-fluid level within the lung fields as seen in this image.

Question 1

The following CT chest shows:

Accepted Answer

A= Tree in Bud appearance, B= Ground glass pattern

Answer

A= Crazy pavement pattern, B= Tree in bud appearance

Answer

A= Mosaic perfusion pattern, B= Crazy pavement pattern

Answer

A= Bronchovascular nodular pattern, B= Ground Glass pattern

Question 2

A 6-month-old child is on Vancomycin for pneumonia for 2 days. He develops worsening of respiratory distress and $\mathrm{SpO}_{2}$ falls to $80 \%$. The CXR performed is shown below. What is the diagnosis?

Accepted Answer

Pneumothorax

Answer

Lung abscess

Answer

Empyema

Answer

Segmental collapse

Question 3

What is the most likely diagnosis based on the chest radiographs shown below?

Accepted Answer

Segmental collapse

Answer

Lung abscess

Answer

Lobar emphysema

Answer

Bronchiectasis

Question 4

Which of the following is shown in the image below?

Accepted Answer

Westermark sign

Answer

Palla sign

Answer

Hampton hump

Answer

Round pneumonia

Question 5

An AIDS patient presents with respiratory distress. CXR shows:

Accepted Answer

Pneumocystis pneumonia

Answer

Miliary TB

Answer

Streptococcal pneumonia

Answer

Lymphocytic interstitial Pneumonitis

Question 6

A breast cancer patient presents with difficulty in breathing. CXR shows:

Accepted Answer

Cannonball metastasis

Answer

Pneumothorax

Answer

Pulmonary artery hypertension

Answer

Interstitial lung disease

Question 7

An adult undergoes multiple FFP transfusions for excessive bleeding after cardiac surgery and develops respiratory distress. CXR done is shown below. What does it indicate?

Accepted Answer

TRALI

Answer

Volume overloading of heart

Answer

Mendelson's syndrome

Answer

Pneumomediastinum

Question 8

What is the diagnosis based on the CXR of a patient of cystic fibrosis shown below?

Accepted Answer

Bi-basilar fibrosis

Answer

Round pneumonia with perihilar shadows

Answer

Hilar lymphadenopathy with coin shadows

Answer

Egg shell calcification

Question 9

A 40-year-old male presents with sudden onset right-sided chest pain and breathlessness following a road traffic accident. On examination, breath sounds are diminished on the right side. The chest X-ray is shown below. What is the most likely diagnosis?

Accepted Answer

Right hydropneumothorax

Answer

Hydatid cyst right lung

Answer

Right pleural effusion

Answer

Perforated abdominal viscus

Question 10

Which is not a finding of the Chest X-ray shown below? (AIIMS May 2017)

Accepted Answer

Narrow vascular pedicle

Answer

Pulmonary venous hypertension

Answer

Increased CT ratio

Answer

Acute cardiophrenic angle

Chest Radiology — MCQs

Chest Radiology — MCQs

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