Chest radiographs in the evaluation of the febrile infant

Chest radiographs are often considered an essential part of the workup of the febrile infant. Anteroposterior and lateral radiographs of the chest are frequently obtained in this group of patients, irrespective of respiratory tract symptoms and/or signs. A total of 226 children (less than or equal to 2 years old) with and without signs and symptoms of lower respiratory tract infections were examined to assess the yield of chest radiographs. The radiograph was considered positive only if a focal parenchymal infiltrate was present. Hyperinflation or bronchial thickening was not included as a positive finding because these children usually do not receive antibiotics despite the fact that viral illness or reactive airway disease may be present. In a retrospective study of 105 infants, confidence intervals for yield were established for children with (95% Cl = 12%, 32%) and without (95% Cl = 0%, 14%) symptoms or signs of lower respiratory tract infection. In a prospective study of 121 infants without chest symptoms or signs, confidence levels for positive yield were better defined (95% Cl = 0%, 3%). The data suggest that obtaining chest radiographs to look for parenchymal infiltrates treatable with antibiotics in infants less than 2 years old is necessary only in those infants who have clinical evidence of lower respiratory tract illness.     

Bronchopulmonary dysplasia: a radiographic and clinical review of 20 patients

This paper reviews the radiological features of 20 infants with bronchopulmonary dysplasia, with particular emphasis on the early radiological findings in these infants, the clinical findings and radiological progression. Of 20 infants, eight had idiopathic respiratory distress in the first week of life, two infants had early radiological abnormalities other than idiopathic respiratory distress and 10 infants had normal initial chest radiographs. The complicating features included lower respiratory infections (88%), patent ductus arteriosus (40%) and areas of atelectasis (40%). Areas of atelectasis were more common in infants with an initially normal chest radiograph than in those with idiopathic respiratory distress syndrome (p = 0.015). Mortality from severe bronchopulmonary dysplasia was 70% in this series.     

Eight cases of severe acute respiratory syndrome presenting as round pneumonia

OBJECTIVE: The purpose of this study was to describe the radiographic findings and evolution of round pneumonia found in eight patients with confirmed severe acute respiratory syndrome (SARS). CONCLUSION: SARS may present as round pneumonia on chest radiographs initially or during the treatment course. It may remain unchanged for up to 9 days before evolution to ill-defined air-space opacities. Radiologists and physicians should consider the possibility of "SARS pneumonia" when spherical air-space opacities are noted on chest radiographs of febrile patients.     

Chest radiograph scoring system for use in pre-term infants.

A scoring system to characterize the pre-term infant's chest radiograph appearance has been evaluated. Chest radiographs taken at 1 month of age in 20 infants (median gestational age 27 weeks) were scored according to abnormalities of lung volume, presence of opacification, interstitial changes and cystic elements (maximum score 17). The median score was 4 (range 1-14); the highest scores were for the only infants with cystic elements and/or interstitial changes on their chest radiographs. The scoring system documented accurately the severity of neonatal respiratory distress; the highest scores occurred in those infants requiring the most prolonged respiratory support, i.e. ventilated beyond 1 week of age (p less than 0.01) and oxygen-dependent beyond 1 month (p less than 0.01). It was also a useful predictor of chronic respiratory problems, with an 88% sensitivity in the detection of infants with the most severe lung function abnormalities at 6 months of age.     

Efficacy of chest radiography in pediatric intensive care

We prospectively evaluated the efficacy and clinical usefulness of bedside chest radiography in a pediatric intensive-care unit. Seven hundred ninety-five radiographs were evaluated in 126 patients over a 10-week period. Eighty-one percent of all radiographs showed one or more cardiopulmonary abnormalities, and 25% of routine radiographs had findings that altered management of patients. Nineteen percent of radiographs, including 17% of routine radiographs, showed a malpositioned tube or catheter. Thirty-five percent of endotracheal tubes shown on postintubation radiographs and 41% of central venous catheters shown on post-catheter placement radiographs were malpositioned. Forty-five percent of radiographs with a previous reading showed a significant interval change. Radiographs in patients 1 year old or younger showed more cardiopulmonary abnormalities (p less than .04), tube or catheter malpositions (p less than .03), and significant interval changes (p less than .03), and they elicited more changes in clinical management (p less than .01) than did radiographs in patients over 1 year old. The frequency of management changes dictated by radiographs increased with increasing amounts of respiratory support (p less than .01). Our data indicate that bedside radiography in the pediatric intensive-care setting has a high efficacy and clinical utility.     

Herpes simplex virus 1 pneumonia: conventional chest radiograph pattern

The aim of this study was to describe the findings on plain chest radiographs in patients with herpes simplex virus pneumonia (HSVP). The study was based on 17 patients who at a retrospective search have been found to have a monoinfection with herpes simplex virus. The diagnosis was established by isolation of the virus from material obtained during fiberoptic bronchoscopy (FOB) which also included broncho-alveolar lavage and tissue sampling. Fourteen patients had a chest radiograph performed within 24 h of the date of the FOB. Two radiographs showed no abnormalities of the lung parenchyma. The radiographs of the other 12 patients showed lung opacification, predominantly lobar or more extensive and always bilateral. Most patients presented with a mixed airspace and interstitial pattern of opacities, but 11 of 14 showed at least an airspace consolidation. Lobar, segmental, or subsegmental atelectasis was present in 7 patients, and unilateral or bilateral pleural effusion in 8 patients, but only in 1 patient was it a large amount. In contradiction to the literature which reports a high correlation between HSVP and acute respiratory distress syndrome (ARDS), 11 of 14 patients did not meet the pathophysiological criteria for ARDS. The radiologist may suggest the diagnosis of HSVP when bilateral airspace consolidation or mixed opacities appear in a susceptible group of patients who are not thought to have ARDS or pulmonary edema. The definite diagnosis of HSV pneumonia can be established only on the basis of culture of material obtained by broncho-alveolar lavage.     

Evaluating current chest imaging practices of pediatric patients with COVID-19: A retrospective analysis

PurposeThis retrospective analysis aims to examine the effectiveness of the current chest imaging guidelines regarding COVID-19 positive pediatric patients on our study group of patients aged 0 to 18.Materials and methodsWe examined clinical and imaging data of 178 pediatric COVID-19 positive patients confirmed by PCR admitted to the Children's Hospital of Los Angeles between March 6, 2020 and June 23, 2020.ResultsOf 178 patients, only 46 (27%) patients underwent any form of chest imaging. Thirteen (28%) of 46 imaged patients had positive chest X-rays (CXR) or computed tomography (CT) chest findings, with 8 (62%) of the 13 patients suggesting pneumonia or multifocal pneumonia, 3 (23%) patients having acute respiratory distress syndrome, and 2 (15%) patients demonstrating left sided pleural effusions thought to be the result of ruptured appendicitis unrelated to their COVID-19 diagnosis. All but one patient had significant prior medical histories with an associated comorbid medical condition. Of the 46 imaged patients, 17 (37%) patients had a negative chest X-ray, and 15 (33%) patients had suggestive findings of viral etiology. 132 patients were not imaged.ConclusionOur study population corroborated current chest imaging guidelines in pediatric patients. Chest imaging modalities such as CXR and CT should be reserved for patients who are severely symptomatic and/or possess prior comorbidities such as immunosuppression, diabetes, asthma, obesity, or where other differential etiologies must be entertained.     

Post-ARDS pulmonary fibrosis in patients with H1N1 pneumonia: role of follow-up CT

Purpose

Our aim was to evaluate the evolution of 20 patients with H1N1 pneumonia, focusing our attention on patients with severe clinical and radiological findings who developed post-acute respiratory distress syndrome (post-ARDS) pulmonary fibrosis.

Materials and methods

Twenty adult patients (nine women and 11 men; mean age 43.5±16.4 years) with a diagnosis of H1N1 infection confirmed by pharyngeal swab came to our attention from September to November 2009 and were followed up until September 2010. All patients were hospitalised in consideration of the severity of clinical findings, and all underwent chest X-ray. Twelve of them underwent at least one computed tomography (CT) scan of the chest.

Results

In 75% of cases (15/20), there was complete resolution of the clinical and radiological findings. Twenty-five percent of patients (5/20) developed acute respiratory distress syndrome (ARDS), which progressed to predominantly peripheral pulmonary fibrosis in 10% (2/20; one died and one had late-onset pulmonary fibrosis, documented on day 68). Moreover, in one patient with a CT diagnosis of pulmonary fibrosis, we observed progressive regression of radiological findings over 4 months of follow-up.

Conclusions

In patients with H1N1 pneumonia, post-ARDS pulmonary fibrosis is not a rare complication. Therefore, a CT scan should be performed in all patients with severe clinical findings. Our study demonstrated that in these patients, fibrosis could present a different spatial distribution and a different temporal trend, with delayed late onset; moreover, in one case, the signs of interstitial lung disease partially regressed over time. Therefore, CT should be considered not only in the diagnostic stage, but also during the follow-up.     

Radiographic appearance and clinical outcome correlates in 26 patients with severe acute respiratory syndrome

OBJECTIVE: We aimed to evaluate the appearance of chest radiographs in patients with severe acute respiratory syndrome (SARS) and correlate these findings with clinical outcomes. MATERIALS AND METHODS: We retrospectively reviewed the initial radiograph and a series of follow-up chest radiographs in 26 patients who had symptoms and signs consistent with SARS. Twenty-five patients completed the full course of radiographs in the hospital. The initial radiographic features and the distribution of parenchymal, mediastinal, and pleural abnormalities for each patient were evaluated. Follow-up radiographic findings were correlated with clinical outcomes for these patients. RESULTS: Initial chest radiographs showed abnormalities in 23 (88%) of 26 subjects. Eighteen patients (69%) had air-space consolidation, two (8%) had ground-glass attenuation, one (4%) had nodules, and two (8%) had mixed consolidation and nodules. Four patients (15%) had pleural effusion. Younger patients and those with normal initial radiographic findings or unifocal lung lesions had better outcomes. CONCLUSION: The initial predominant radiographic feature of SARS was air-space consolidation in the lateral and lower lung zones. Progressive deterioration to diffuse unilateral or bilateral consolidation in the series of follow-up chest radiographs is associated with a poor prognosis.     

Radiological findings of pneumonia in patients with swine-origin influenza A virus (H1N1)

Purpose

During spring 2009, a pandemic swine-origin influenza A (H1N1) virus (S-OIV) emerged and spread globally. We describe the chest X-ray and computed tomography (CT) findings of 40 patients with pneumonia due to S-OIV observed in our institution.

Material and methods

Among 534 patients with S-OIV, according to the US Centers for Disease Control and Prevention case definition, seen between June and November 2009, 121 underwent chest X-ray and 40 (median age 44 years, range 16–79) had pneumonia. The initial chest radiographs were evaluated for pattern, distribution and extent of lung abnormalities. Unenhanced chest CT scans were performed in two patients and were reviewed for the same findings. Underlying medical conditions were present in 42% of patients (17/40).

Results

Our patients had predominantly mild illness, and pneumonia was observed in 40 individuals (40/121 patients who had chest X-rays, 33%; and 40/534 patients with S-OIV, 7.5%). However, S-OIV can cause severe illness requiring admission to the intensive care unit for advanced mechanical ventilation and extracorporeal life support, including adult respiratory distress syndrome (ARDS) and death. The major radiological abnormalities observed were interstitial changes (60.0%), with (22.0%) or without patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones (7.5%). Extensive disease was seen in 37.5% (15/40), and ARDS was observed in three individuals (0.30%)with underlying medical conditions. Subtle pleural effusion was noted in four patients.

Conclusions

In our series, the most frequent pneumonia patterns observed during S-OIV (H1N1) virus were interstitial changes and patchy ground-glass appearance, mostly bilateral, and located in the lower lung zones. CT, performed in severely ill patients, confirmed the ARDS identified with chest X-rays, better depicting the features and extent of lung abnormalities.     

Interobserver variability in the radiographic diagnosis of adult outpatient pneumonia.

Acute chest radiographs were obtained from 319 adult patients with acute respiratory infections. Where a lower respiratory infection was diagnosed, follow-up chest radiographs were obtained in most patients. A radiologic panel diagnosed pneumonia in 21 patients. The agreements between the panel and 3 independent interpreters, 2 residents in radiology, and one senior chest physician, were assessed. Also the reports given by the specialist in radiology at the Department of Radiology were compared with the panel's evaluation. While the kappa-agreements between the panel's interpretations and those by the Department of Radiology and the consultant in chest medicine was 0.71 and 0.72, respectively, the corresponding kappa-values between the residents and the panel was only 0.50. The proportion of agreement when pneumonia was diagnosed was 0.56 between the panel and the Department of Radiology, and 0.59 between the panel and the chest consultant, compared to 0.36 between the panel and the residents. The study demonstrates the difficulty of diagnosing outpatient pneumonia and the importance of experience.     

Therapeutic neuromuscular paralysis in neonates: characteristic radiographic features

Neonates with respiratory distress requiring mechanical ventilation may be treated with muscular paralysis to improve oxygenation. This results in characteristic radiographic features that relate in part to the specific drug used. The radiographic signs are: bell-shaped chest, decreased bowel gas, and soft-tissue edema. When all three findings are present, the use of neuromuscular blockade can be suggested from the radiographs alone without the aid of clinical history. Radiographs of 57 infants treated with muscular paralysis and mechanical ventilation were compared to 20 infants treated with mechanical ventilation alone. In paralyzed patients, a characteristic bell-shaped chest was seen in 24 of 57 and decreased bowel gas in 46 of 52. Soft-tissue edema was seen in patients treated with metocurine, and the incidence increased with duration of therapy (18 of 25 treated for 5 or more days); it was not radiographically detected in patients treated with d-tubocurarine (0 of 13). Bell-shaped chest, decreased bowel gas, and soft-tissue edema occurred one, three, and one times, respectively, in 20 nonparalyzed control infants, and each time the findings carried significantly different clinical implications. All cases were reviewed to determine if pulmonary edema can result from mobilization of soft-tissue edema fluid after cessation of neuromuscular paralysis, and this was found not to occur.     

Pulmonary lymphangiomyomatosis: correlation of CT with radiographic and functional findings

In 14 patients with biopsy-proved lymphangiomyomatosis, disease extent at computed tomography (CT) was correlated with findings at chest radiography and pulmonary-function testing. The CT scans and chest radiographs were read independently by two chest radiologists. Disease extent was assessed on CT scans by using a visual score (0%-100% involvement of the lung parenchyma) and on radiographs by using an adaptation of the International Labour Office classification of the pneumoconioses. There was good concordance between the two observers for CT and radiographic scores (Kendall tau greater than or equal to .86, P less than .01). A significant but relatively low correlation was present between CT findings and radiographic severity of disease (r = .59, P less than .05). Impairment in gas exchange as assessed with the diffusing capacity correlated better with disease extent seen on CT scans (r = .69) than with chest radiographic findings (r = .59). Three patients had evidence of parenchymal disease on the CT scans but not on the radiographs. In one patient CT findings were negative despite a positive finding on chest radiographs. The authors conclude that CT is superior to chest radiography in the assessment of patients with lymphangiomyomatosis.     

Computed tomography evaluation of cavitary necrosis in complicated childhood pneumonia

The purpose of the present study was to retrospectively investigate the chest radiograph (CR) and CT findings of childhood pneumonia complicated by cavitary necrosis, and to evaluate the role of CT in decision-making for surgical intervention. Chest CT was performed in 51 patients presenting with persistent or progressive pneumonia, respiratory distress and sepsis despite 7-10 days of appropriate antibiotic treatment and closed tube drainage. Chest radiograph and CT findings were retrospectively evaluated in 23 patients (45%) with cavitary necrosis. Chest radiographs showed consolidation in 19 of 23 patients, cavitation in five patients, parapneumonic effusions in 17 patients and air-fluid levels in the pleural space in one patient. The CT scans demonstrated consolidation and cavitary necrosis in all patients. There were parapneumonic effusions in all patients with concomitant loculated collections in six patients. Twenty-two of 23 patients had pleural thickening. In seven patients there were air-fluid levels in the pleural space. In five of these patients, CT scans demonstrated bronchopleural fistulae. On the basis of the CT and clinical findings, 11 patients underwent surgical intervention. Computed tomography is superior to CR for demonstrating cavitary necrosis complicating pneumonia, and other parenchymal and pleural complications. It also has a crucial decision-making role for surgery.     

Radiology residents' on-call interpretation of chest radiographs for pneumonia

RATIONALE AND OBJECTIVES: This study is designed to assess the performance of radiology residents in interpreting emergency department chest radiographs for pneumonia and to characterize chest radiographic findings in patients for which interpretation was amended by an attending radiologist. MATERIALS AND METHODS: We retrospectively reviewed all amended reports for chest radiographs performed on emergency department patients July 2002-June 2003. Reports preliminarily interpreted by residents and amended by a board-certified staff radiologist for the presence or absence of pneumonia were identified. A panel of three experienced radiologists, blinded to reports, jointly reviewed each chest radiograph. If the panel diagnosed pneumonia, the chest radiograph was evaluated for the projection that best showed the pneumonia, its size and location, and the presence or absence of the following features: increased opacity, air bronchograms, loss of vascular markings, silhouette sign, and linear opacities. The resident's post-graduate year (PGY) training level was noted. RESULTS: One percent (134/12,600 reports) of chest radiographic reports were amended for the presence or absence of pneumonia. One hundred chest radiographs were available and comprised the series. There were 56 females and 44 males with a mean age of 45 years (range, 1-99 years). The staff radiologist diagnosed pneumonia in 79% (79/100 radiographs). The panel agreed with the staff in 77% (kappa = 0.76) and the resident in 23% (kappa = 0.43). The panel diagnosed pneumonia in 60% (60/100 radiographs) with the following chest radiographic findings: 100% (60/60), increased opacity; 37% (22/60), air bronchograms; 72% (43/60), loss of vascular markings; 40% (24/60), silhouette sign; and 20% (12/60), linear opacities. The pneumonia was right sided in 52% (31/60), left sided in 37% (22/60), and bilateral in 11% (7/60). Right-sided pneumonias were equally distributed among the three lobes, and left-sided pneumonias had a lower-lobe predominance of 77% (17/22). Seventy-five percent (45/60) of pneumonias were segmental or smaller, and 82% (49/60) of chest radiographs showing pneumonia had both posteroanterior and lateral projections. The pneumonia was conspicuous on only one projection in 43% (21/49); the posteroanterior view in 22% (11/49), and the lateral view in 20% (10/49). Eighty-one percent (81/100) of interpreting residents were PGY-3. CONCLUSION: Interpretation of chest radiographs for pneumonia by PGY-3 residents has a low error rate. Missed pneumonias often were segmental or smaller and conspicuous on only one projection.     

Imaging of cavitary necrosis in complicated childhood pneumonia

The aim of this study was to illustrate the chest radiographs (CR) and CT imaging features and sequential findings of cavitary necrosis in complicated childhood pneumonia. Among 30 children admitted in the Pediatric Intensive Care Unit for persistent or progressive pneumonia, respiratory distress or sepsis despite adequate antibiotic therapy, a study group of 9 children (5 girls and 4 boys; mean age 4 years) who had the radiographic features and CT criteria for cavitary necrosis complicated pneumonia was identified. The pathogens identified were Streptococcus pneumoniae( n=4), Aspergillus( n=2), Legionella( n=1), and Staphylococcus aureus( n=1). Sequential CR and CT scans were retrospectively reviewed. Follow-up CR and CT were evaluated for persistent abnormalities. Chest radiographs showed consolidations in 8 of the 9 patients. On CT examination, cavitary necrosis was localized to 1 lobe in 2 patients and 7 patients showed multilobar or bilateral areas of cavitary necrosis. In 3 patients of 9, the cavitary necrosis was initially shown on CT and visualization by CR was delayed by a time span varying from 5 to 9 days. In all patients with cavities, a mean number of five cavities were seen on antero-posterior CR, contrasting with the multiple cavities seen on CT. Parapneumonic effusions were shown by CR in 3 patients and in 5 patients by CT. Bronchopleural fistulae were demonstrated by CT alone ( n=3). No purulent pericarditis was demonstrated. The CT scan displayed persistent residual pneumatoceles of the left lower lobe in 2 patients. Computed tomography is able to define a more specific pattern of abnormalities than conventional CR in children with necrotizing pneumonia and allows an earlier diagnosis of this rapidly progressing condition. Lung necrosis and cavitation may also be associated with Aspergillus or Legionella pneumonia in the pediatric population.     

Cardiothoracic ratio in Nigerian newborn infants

Cardiothoracic ratio was calculated from measurements made on the frontal radiographs of 172 normal (appropriate for gestational age) Nigerian newborn infants. The normal ratio was compared with those of 30, 32 and 42 neonates with respiratory distress syndrome, birth asphyxia and parenchymal lung disease respectively. The ratio for normal neonates was 49.12%. It was however significantly increased in respiratory distress syndrome (51.18%) and asphyxia (50.81%). The cardiothoracic ratio values obtained in this study are lower than those in Caucasian newborn infants.     

高分辨力CT在肾移植术后疑似肺炎患者中的应用价值

目的:评价高分辨率CT(HRCT)在诊断肾移植术后疑似肺炎中的应用价值。方法:33例肾移植术后疑似肺炎患者行胸片、胸部HRCT检查。所有患者均经影像学、实验室检查及临床随访而明确诊断。对33例患者的胸片和HRCT图像进行回顾性对比分析。结果:33例中10例(30.3%)胸片未见异常,其中9例HRCT提示肺炎并最终证实;23例胸片和HRCT均见异常,22例最终证实为肺炎,其中18例HRCT可提供更多更准确的信息,仅4例(12.1%)胸片与HRCT及最终诊断结果基本一致。结论:HRCT较胸片更敏感,有助于早期确诊肺炎,所有疑似肺炎的肾移植患者均应行HRCT检查,肾移植术后肺炎常见HRCT改变为磨玻璃样改变、小结节影和小片状实变。     

Primary infantile hyperparathyroidism: clinical,laboratory, and radiographic features in 21 cases

Two cases of primary infantile hyperparathyroidism (PIH) are reported. In both cases the diagnosis was initially suspected from chest radiographs which were obtained to assess the etiology of fever and respiratory distress in one case and heart murmur in another. The first case responded well to subtotal parathyroidectomy. The second case had many unique features. (1) She never became overtly symptomatic. (2) She displayed a constellation of findings that are not yet emphasized. (3) Her indisputable radiographic findings of hyperparathyroidism vanished spontaneously by two months of age, whereas her biochemical alterations have persisted up to now, 21/2 years after birth. (4) Three members of her family have subclinical hyperparathyroidism (elevated serum parathormone, hypercalcemia, and hypophosphatemia).Our review of 19 more cases showed that PIH has no specific clinical symptoms and/or signs. Of the laboratory findings, hypercalcemia was most consistantly encountered. The radiographic finding, although not identical to those described in hyperparathyroid adults, had the greatest diagnostic specificity. The disorder carried a grave prognosis if not diagnosed promptly and managed surgically.