Pediatric Radiology Practice Questions

Q: An 11-month-old child presents with recurrent episodes of UTI. MCUG shows VUR:

Grade III. ***Grade III*** - The MCUG image demonstrates **reflux into the pelvicalyceal system** with tortuosity of the ureter. There is also evidence of **mild calyectasis**. This degree of reflux, characterized by reflux into the renal pelvis and calyces with mild dilatation and blunting, aligns with Grade III VUR. - Recurrent UTIs in a child are a common presentation that warrants investigation for VUR, and a Grade III VUR requires close monitoring and may necessitate intervention to prevent renal damage. *Grade I* - Grade I VUR involves reflux only into the **ureter** and does not reach the renal pelvis or calyces. - The provided image clearly shows contrast extending beyond the ureter into the collecting system of the kidney, ruling out Grade I. *Grade II* - Grade II VUR is characterized by reflux into the **renal pelvis and calyces** without any dilation or blunting of the calyces or tortuosity of the ureter. - The image shows some degree of **dilatation of the calyces and tortuosity of the ureter**, which is more severe than Grade II and indicative of Grade III. *Grade IV* - Grade IV VUR involves more significant findings, including **moderate dilation of the renal pelvis and calyces** with moderate blunting of the fornices. There is significant ureteral tortuosity. - While there is some dilation and tortuosity in the image, it does not reach the severe level typically seen in Grade IV, which would involve more pronounced blunting and more extensive hydronephrosis.

Q: The given radiograph is diagnostic of:

Rickets. ***Correct Option: Rickets*** - The radiograph displays classic signs of **rickets**, including **widened and frayed growth plates** (physeal plates) in the long bones, particularly visible at the distal femur and wrist - Other features often seen in rickets, and suggested by the image, are **cupping and splaying of the metaphyses**, indicating defective mineralization of bone - Rickets results from vitamin D deficiency leading to impaired calcium and phosphate metabolism, causing defective bone mineralization *Incorrect Option: Scurvy* - Scurvy, due to **vitamin C deficiency**, presents with distinct radiological findings such as the **Wimberger ring sign** (opacification outlining the epiphysis) and **corner fractures** (Pelkan spurs), which are not prominently depicted - While periosteal hemorrhage can occur in scurvy, the characteristic widening and fraying of growth plates seen here are more indicative of rickets - Scurvy affects collagen formation, not mineralization like rickets *Incorrect Option: Battered baby syndrome* - Images in **battered baby syndrome** (child abuse) typically show **multiple fractures at different stages of healing**, epiphyseal separations, and metaphyseal corner fractures - These features are distinct from the bone mineralization defects characteristic of rickets, and there are no clear signs of multiple traumatic injuries - The systematic bilateral changes seen in rickets would not be typical of inflicted trauma *Incorrect Option: Osteogenesis imperfecta* - **Osteogenesis imperfecta** is characterized by extreme **bone fragility** leading to frequent fractures, often with associated blue sclerae and hearing loss - The radiographic findings would predominantly be multiple fractures and osteopenia (reduced bone density), without the specific growth plate abnormalities seen in rickets - This is a collagen disorder causing generalized bone weakness, not a mineralization disorder

Q: Comment on the arrow marked structure in CXR of an infant: (Recent NEET Pattern 2018-19)

Sail sign. ***Sail sign*** - The arrow points to an elevated, well-defined triangular shadow in the right upper mediastinum, characteristic of the **thymus gland** in an infant. - This appearance is known as the **"sail sign"** due to its resemblance to a boat's sail, caused by the normal shape of the thymus in young children. *Lingular lobe pneumonia* - Lingular lobe pneumonia would appear as an **area of consolidation** or opacification, usually in the left mid-to-lower lung field, which is not depicted here. - This pathology typically results in a loss of the normal markings of the lung parenchyma, unlike the clear outline seen in the image. *Pneumothorax* - A pneumothorax would present as a **collection of air** in the pleural space, characterized by the absence of lung markings in the affected area and a visible visceral pleural line. - There is no evidence of displaced lung tissue, collapsed lung, or an abnormal air collection in the image. *Dextrocardia* - Dextrocardia refers to a condition where the **heart is located on the right side** of the chest. - In this image, the cardiac silhouette is clearly on the left side, indicating a normally positioned heart.

Q: A child presents with the following appearance, seborrheic dermatitis, hepatosplenomegaly, and pancytopenia. X-ray of the skull is shown. What is the diagnosis?

Geographical skull. ***Geographical skull*** - The combination of **seborrheic dermatitis**, **hepatosplenomegaly**, **pancytopenia**, and characteristic skull X-ray findings (multiple lytic lesions) in a child suggests **Langerhans Cell Histiocytosis (LCH)**. - The skull X-ray shows multiple, sharply demarcated, irregular lytic lesions of varying sizes, resembling a **map or "geographical" pattern**, which is characteristic of LCH. *Pepper pot skull* - This appearance is characterized by **numerous small lytic lesions** resembling tiny holes, typically seen in conditions causing widespread bone resorption, such as **hyperparathyroidism** or **multiple myeloma**. - The child's x-ray depicts larger, more irregular lytic lesions rather than diffuse small punctate ones. *Hair-on-end appearance* - This term describes **new bone formation perpendicular to the inner table of the skull**, giving the skull a "hair-on-end" or "sunburst" appearance on X-ray. - It is classically associated with severe **chronic hemolytic anemias** like **thalassemia major** and **sickle cell anemia**, which do not present with geographical skull lesions or the other clinical features mentioned. *Artifacts* - **Artifacts** are extraneous findings on an imaging study that are not due to the patient's anatomy or pathology (e.g., patient motion, metallic objects, processing errors). - The described and visual findings are consistent with specific bony lesions, not imaging errors.

Q: A "double bubble" sign on an antenatal ultrasound examination in a gravid woman is diagnostic of

Duodenal atresia. ***Duodenal atresia*** - The **"double bubble" sign** on antenatal ultrasound is highly characteristic of duodenal atresia, representing a dilated **stomach** and a dilated **proximal duodenum**. - This finding indicates an **obstruction distal to the pylorus**, preventing normal passage of fluid and gas. *Anencephaly* - Anencephaly is a severe birth defect where a baby is born without parts of the **brain** and **skull**, and it is characterized by the absence of the skull vault. - It is identified by the absence of the **cranial vault** and **cerebral hemispheres**, not by an abdominal "double bubble." *Meningomyelocele* - Meningomyelocele is a type of **spina bifida** where the spinal cord and meninges protrude through an opening in the back. - This condition is typically diagnosed by visualizing a **spinal defect** with a sac-like protrusion, not gastric or duodenal distension. *Hydronephrosis* - Hydronephrosis involves the **swelling of one or both kidneys** due to a buildup of urine, often caused by an obstruction in the urinary tract. - It is identified by **dilated renal pelves** and calyces on ultrasound, not the "double bubble" sign, which relates to the gastrointestinal tract.

Q: A child presents with cyanosis. His chest radiograph is shown below. What is the diagnosis?

Tetralogy of Fallot (TOF). ***Tetralogy of Fallot (TOF)*** - The chest radiograph shows a **boot-shaped heart (coeur en sabot)** due to **right ventricular hypertrophy** and a **concave pulmonary artery segment** (absent main pulmonary artery segment), which is characteristic of TOF. - The patient also presents with **cyanosis**, a common symptom of TOF due to right-to-left shunting. *Transposition of great arteries (TGA)* - TGA typically presents with a **"egg-on-a-string" appearance** on chest radiograph, indicating a narrow superior mediastinum and increased pulmonary vascular markings, which is not seen here. - While patients with TGA are cyanotic, the cardiac silhouette on this radiograph is inconsistent with the classic TGA findings. *Ebstein's anomaly* - Ebstein's anomaly is characterized by **apical displacement of the tricuspid valve**, leading to a large right atrium and massive **cardiomegaly** on chest X-ray, often described as a "box-shaped" heart, which is not evident in the provided image. - While it causes cyanosis, the heart size in the image is not markedly enlarged enough to suggest Ebstein's anomaly. *Total anomalous pulmonary venous return (TAPVC)* - TAPVC typically presents with a **"snowman" or "figure-of-8" appearance** on chest X-ray due to a dilated superior vena cava and left brachiocephalic vein, or a small heart with increased pulmonary vascularity, neither of which is present in the image. - Although TAPVC causes cyanosis, the specific radiographic features like the "boot-shaped" heart rule out this diagnosis.

Q: What condition is associated with the sign seen in the given USG?

Spina bifida. ***Spina bifida*** - The ultrasound image displays the **"lemon sign"** (frontal bone indentation), which is a classic indicator of **spina bifida** on antenatal ultrasound. - The lemon sign is caused by **scalloping of the frontal bones** due to caudal displacement of brain tissue (Arnold-Chiari malformation type II) secondary to an open spinal defect. - This sign is most commonly seen in the **second trimester** and is associated with neural tube defects. *Anencephaly* - **Anencephaly** presents with absence of the cranial vault and cerebral hemispheres on ultrasound. - The characteristic finding is the **"frog-eye appearance"** with protruding orbits, not frontal bone scalloping. - This is incompatible with life and has a distinctly different ultrasound appearance. *Dandy-Walker malformation* - **Dandy-Walker malformation** shows an enlarged posterior fossa with cystic dilatation of the fourth ventricle and hypoplasia of the cerebellar vermis. - It may present with the **"banana sign"** (cerebellar compression), but not the lemon sign. - This is a posterior fossa abnormality, not associated with frontal bone changes. *Encephalocele* - **Encephalocele** presents as a herniation of brain tissue and meninges through a cranial defect, typically occipital. - Ultrasound shows a **cystic mass protruding from the skull**, not frontal bone indentation. - While it's a neural tube defect, it has a different ultrasound appearance than the lemon sign.

Q: Investigation of choice for Posterior urethral valves?

Micturating Cystourethrography (MCU). ***Micturating Cystourethrography (MCU)*** - The **Micturating Cystourethrography (MCU)** is the gold standard for diagnosing posterior urethral valves (PUV) as it directly visualizes the posterior urethra during voiding. - It classically shows a **dilated posterior urethra** with a narrow opening at the level of the valves, often accompanied by **vesicoureteral reflux** and bladder wall abnormalities. *Ultrasound* - **Antenatal ultrasound** can suggest PUV by showing bilateral **hydronephrosis**, a dilated bladder, and thick-walled bladder with a "keyhole sign" (dilated posterior urethra). - However, ultrasound alone **cannot definitively diagnose** the valves or rule out other causes of obstruction. *Retrograde urethrography* - **Retrograde urethrography (RGU)** involves injecting contrast against the flow of urine, which can mask the presence of posterior urethral valves, as they are typically obstructive to antegrade flow. - While RGU can highlight urethral strictures and other anterior urethral pathologies, it is **not ideal** for visualizing posterior urethral valves. *Intravenous Pyelography* - **Intravenous Pyelography (IVP)** assesses kidney function and the collecting system, but it provides **limited detailed visualization** of the urethra itself. - While it might show features of obstructive uropathy like **hydronephrosis** or delayed excretion, it cannot directly confirm the presence or location of posterior urethral valves.

Q: The most likely diagnosis in a newborn who had a radiopaque shadow with an air-fluid level in the chest along with hemivertebrae of the 6th thoracic vertebra on plain X-ray is –

Oesophageal duplication cyst. ***Oesophageal duplication cyst*** - The presence of a **radiopaque shadow with an air-fluid level** in the chest, coupled with **hemivertebrae of the 6th thoracic vertebra**, is highly suggestive of an esophageal duplication cyst due to their common developmental origin and intrathoracic location. - **Esophageal duplication cysts** are foregut anomalies that can present as cystic masses containing fluid, and their close association with vertebral anomalies like hemivertebrae points to a developmental error during embryogenesis affecting both structures. *Bronchogenic cyst* - While bronchogenic cysts are also foregut anomalies and can appear as **radiopaque shadows**, they typically do not present with an **air-fluid level** unless secondarily infected or communicating with the airway, and their association with vertebral anomalies is less direct. - These cysts usually present as a **well-circumscribed, non-communicating mass**, and an air-fluid level usually indicates rupture or infection. *Congenital diaphragmatic hernia* - A congenital diaphragmatic hernia involves the **displacement of abdominal contents into the chest cavity** through a defect in the diaphragm, which would manifest as multiple intestinal loops and air-filled structures in the chest. - While it can present with air-fluid levels (from bowel gas), it is not typically associated with **hemivertebrae**, and the radiopaque shadow would be less defined as a single cyst. *Staphylococcal pneumonia* - Staphylococcal pneumonia in a newborn can lead to **pneumatoceles (air-filled cysts)** that may contain air-fluid levels, but it is an infectious process that would be accompanied by signs of infection like fever and respiratory distress. - This condition is unlikely to present with an associated **vertebral anomaly** like hemivertebrae, which points to a congenital developmental abnormality rather than an acquired infectious cause.

Question 1

Excretory urogram in a two-year-old child with recurrent UTI shows:

Accepted Answer

Drooping water lily sign

Answer

Horse shoe kidney

Answer

Flower vase kidney

Answer

Duplication of kidney

Question 2

An 11-month-old child presents with recurrent episodes of UTI. MCUG shows VUR:

Accepted Answer

Grade III

Answer

Grade I

Answer

Grade II

Answer

Grade IV

Question 3

The given radiograph is diagnostic of:

Accepted Answer

Rickets

Answer

Scurvy

Answer

Battered baby syndrome

Answer

Osteogenesis imperfecta

Question 4

Comment on the arrow marked structure in CXR of an infant: (Recent NEET Pattern 2018-19)

Accepted Answer

Sail sign

Answer

Lingular lobe pneumonia

Answer

Pneumothorax

Answer

Dextrocardia

Question 5

A child presents with the following appearance, seborrheic dermatitis, hepatosplenomegaly, and pancytopenia. X-ray of the skull is shown. What is the diagnosis?

Accepted Answer

Geographical skull

Answer

Pepper pot skull

Answer

Hair-on-end appearance

Answer

Artifacts

Question 6

A "double bubble" sign on an antenatal ultrasound examination in a gravid woman is diagnostic of

Accepted Answer

Duodenal atresia

Answer

Anencephaly

Answer

Meningomyelocele

Answer

Hydronephrosis

Question 7

A child presents with cyanosis. His chest radiograph is shown below. What is the diagnosis?

Accepted Answer

Tetralogy of Fallot (TOF)

Answer

Transposition of great arteries (TGA)

Answer

Ebstein's anomaly

Answer

Total anomalous pulmonary venous return (TAPVC)

Question 8

What condition is associated with the sign seen in the given USG?

Accepted Answer

Spina bifida

Answer

Anencephaly

Answer

Dandy-Walker malformation

Answer

Encephalocele

Question 9

Investigation of choice for Posterior urethral valves?

Accepted Answer

Micturating Cystourethrography (MCU)

Answer

Ultrasound

Answer

Retrograde urethrography

Answer

Intravenous Pyelography

Question 10

The most likely diagnosis in a newborn who had a radiopaque shadow with an air-fluid level in the chest along with hemivertebrae of the 6th thoracic vertebra on plain X-ray is –

Accepted Answer

Oesophageal duplication cyst

Answer

Bronchogenic cyst

Answer

Congenital diaphragmatic hernia

Answer

Staphylococcal pneumonia

Pediatric Radiology — MCQs

Pediatric Radiology — MCQs

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