CASE 1
A 1-year-old boy presents with recurrent cough.
Figure 1: Chest radiograph showing an enlarged right thymus with a positive “sail sign”. The cardiac size and shape are normal, and the lung fields are clear
DISCUSSION
The thymus is a lymphatic organ which plays a vital role in the exhibition of cellular and humoral immunity. It is relatively large in young children, and it is well-demonstrated on the chest radiograph up to the age of 3 years. As the immune system becomes well-established, the thymus undergoes progressive involution and becomes replaced by fat.
The morphology of the thymus is very variable, and it can extend superiorly to the thyroid and inferiorly to the diaphragm.2 This variable size and appearance can be a cause of misdiagnosis and unnecessary intervention. The thymus can shrink rapidly in response to bodily stress, but during recovery it may return to its former size or become larger, a process called rebound hyperplasia.
Apart from the chest radiograph, the thymus is frequently imaged by ultrasonography and CT. On the chest radiograph, the “sail sign” is the straight appearance of the inferior border of the thymus abutting the transverse fissure. The ‘thymic wave sig’ is created by the impression of the anterior ribs on the thyroid.
FURTHER READING
- Han BK, Suh YL, Yoon HK. Thymic ultrasound. Intrathymic anatomy in infants. Pediatr Radiol. 2001;31(7):474–9.
CASE 2
A 6-month-old baby with a history of recurrent cough and hiccups. He had been treated at a rural clinic as a case of recurrent pneumonia.
Figure 1: AP chest X-ray showing multiple gas-filled viscera in the left hemithorax, causing mediastinal shift to the right(Courtesy: Dr Adekunle Abdulkadir)
Diagnosis: Congenital diaphragmatic hernia.
DISCUSSION
Congenital diaphragmatic hernia (CDH) is estimated to occur in 1:4,000 live births. It is associated with a variable degree of pulmonary hypoplasia, as the herniated viscera interfere with normal development of the lung in utero. In 95% of cases, the diaphragmatic defect occurs on the left and is posterolateral (Bochdalek). There is a 40–50% association with other malformations such as central nervous system, digestive, cardiac and urogenital anomalies.
The typical clinical presentation of CDH is respiratory distress occurring immediately after birth or in the first few hours or days of life. Exceptionally, it can present at an older age, and its symptoms then frequently reflect gastrointestinal obstruction or mild respiratory symptoms.
Prenatal diagnosis of CDH can be made at ultrasonography and by MRI. The latter more accurately depicts the lung and herniated bowel which may sometimes be difficult to identify by ultrasound.4 The recent advances in postnatal intensive respiratory supportive therapy and innovative surgical techniques in specialized tertiary centers have had a major impact on survival of babies with CDH. Despite these advances, the mortality rate remains as high as 50–60%.
FURTHER READING
- Bohn D. Congenital diaphragmatic hernia. Am J Respir Crit Care Med. 2002;166:911–5.
- Chavhan GB, Babyn PS, Cohen RA, Langer JC. Multimodality imaging of the pediatric diaphragm: Anatomy and pathologic conditions. Radiographics. 2010;30:1797–817.
CASE 3
A 14-hour-old female newborn was brought to hospital because of a wide chest defect containing a pulsating mass. She was born to an unbooked 23-year-old woman who had an uneventful home delivery at term.
Figure 1: Photograph of the neonate with extrathoracic heart (ectopia cordis) emerging through a sternal cleft. Note the attachment of the umbilicus at the xiphisternum
Figures 2A and B: AP and lateral babygrams showing complete extrathoracic heart. Note the depressed precordium(Courtesy: Dr Adekunle Abdulkadir)
DISCUSSION
Ectopia cordis is an extremely rare malformation resulting from failure of fusion of the left and the right sternal anlage at about the ninth embryonic week. It usually occurs as a part of the pentalogy of Cantrell, also known as thoracoabdominal syndrome or pentalogy syndrome. It is a rare disorder consisting of defects of the anterior chest and abdominal walls, anterior diaphragm, sternum, pericardium and heart. This failure of midline fusion of the sternum results in sternal cleft with the heart being partly or completely outside the thorax. Herniation of bowel and other intra-abdominal structures through a diaphragmatic defect can lead to significant respiratory embarrassment.
Prenatal diagnosis of thoracic ectopia cordis can readily be made with ultrasonography and fetal MRI, permitting prenatal counseling, planning for delivery and possible postnatal intervention. The management of complete ectopic cordis is still very challenging. The chest deformity, with an anteroposterior diameter less than that of the heart, poses space limitations, with a high possibility of cardiac tamponade after sternal closure. There is also the challenge of raising a sufficient skin flap to cover the wide defect. Death ensues within the first year of life in over 90% of the reported cases.
FURTHER READING
- Cabrera A, Rodrigo D, Luis MT, Pastor E, Galdeano JM, Esteban S. Ectopia cordis and cardiac anomalies. Rev Esp Cardiol. 2002;55:1209–12.
- Cantrell JR, Haller JA, Ravitch MM. A syndrome of congenital defects involving the abdominal wall, sternum, diaphragm, pericardium and heart. Surg Gynecol Obstet 1958;107:602–4.
- Engum SA. Embryology, sternal clefts, ectopia cordis, and Cantrell's pentalogy. Semin Pediatr Surg. 2008;17:154–60.
CASE 4A
A male neonate delivered at 32 weeks gestation presented with severe tachypnea shortly after birth.
Figure 1: Chest radiograph at 1 hour shows diffuse reticulogranular opacities in both lungs. The cardiac size and shape are within normal limits
Figure 2: A follow-up radiograph at 3 hours shows opacity of both lung fields, despite the insertion of an endotracheal tube. Note the presence of extensive air bronchograms
Diagnosis: Surfactant deficiency syndrome.
CASE 4B
Another baby with surfactant deficiency disease had prolonged positive pressure assisted respiration with high oxygen concentration.
Figure 1: Chest radiograph shows cystic spaces of varying sizes in both lungs with fibrotic areas, nonuniform pulmonary aeration and pulmonary emphysema. Features are typical of bronchopulmonary dysplasia
DISCUSSION
Surfactant deficiency syndrome (SDS), otherwise known as hyaline membrane disease or respiratory distress syndrome of the newborn, is typically a disease of the premature neonate delivered before 36 weeks and weighing less than 2,500 gram. Surfactant helps lower the surface tension in the alveoli, preventing them from collapsing at each expiration. The premature neonate is deficient in surfactant, and hence the pulmonary changes.
There is a higher prevalence of SDS in babies delivered by cesarean section and babies of diabetic mothers.
The hallmark diagnostic features of SDS on chest X-ray are a bell-shaped thorax with reduced lung volume due to under aeration, a diffuse reticulonodular pattern, and air bronchogram. Apart from the administration of surfactant, treatment involves mechanical ventilation and administration of concentrated oxygen.
9Common complications of the oxygen therapy include bronchopulmonary dysplasia (See Case 4B, Fig. 1), pneumothorax and pneumomediastinum.
FURTHER READING
- Gerten KA, Coonrod DV, Bay RC, et al. Cesarean delivery and respiratory distress syndrome: Does labor make a difference? Am J Obstet Gynecol. 2005;192(3):1061–4.
- Paschechera R, Andrisani MC, et al. Diagnostic imaging of hyaline membrane disease. Rays. 2004;29(2):175–8.
CASE 5
An 18-year-old male, known sickle cell disease patient, was admitted via emergency with a history of low-grade fever, cough and acute chest pain. He was mildly jaundiced and tachypneic. Chest X-rays were obtained on admission and after 24 hours shown in the following figures, respectively.
Figure 1: Plain PA chest X-ray reveals moderate generalized cardiomegaly, prominent main pulmonary and hilar vessels and left lower lobe consolidation. The ribs, scapulae and clavicles show increased density and coarse trabeculation
Figure 2: 24 hours later, the chest X-ray shows bilateral pneumonic consolidation and left pleural effusion. The appearances indicate the so-called acute chest syndrome (ACS) of sickle cell disease
DISCUSSION
There is an increased risk of pneumonia and pulmonary infarction in patients with sickle cell disease. Distinguishing between these two, both clinically and on imaging, can be difficult. Because of this, the general term “acute chest syndrome” is often used to describe fever, a pulmonary process and radiographic evidence of new pulmonary consolidation in a patient with sickle cell hemoglobinopathy. ACS is a common cause of hospitalization in these patients and mortality. Radiographic findings include confluent lobar or segmental consolidation, interstitial infiltration, pulmonary edema (alveolar or interstitial), cardiomegaly and rib infarcts. HRCT may reveal areas of ground-glass opacification and hypo-perfusion.
FURTHER READING
- Maitre B, Habibi A, Roudol-Thorarah F, et al. Acute chest syndrome in adults with sickle cell disease. Chest. 2000;117:1386–92.
CASE 6
A 40-year-old female presented with persistent back pain over three months, anorexia and intermittent fever. Physical examination was normal.
Figure 1: Chest radiograph shows normal heart and lung fields. A left paravertebral soft tissue density is shown (arrows). Destructive changes involving the 6th and 7th dorsal vertebrae were shown in more penetrated radiographs
Figure 2B: Figures 2A and B T2-weighted and T1-contrast enhanced images show extensive osteolytic destruction of vertebrae and a large paravertebral abscess with peripheral contrast enhancement. The appearances indicate spinal tuberculosis (Pott's disease)
DISCUSSION
Tuberculosis remains a worldwide health problem, and is still a leading cause of death, especially in third world countries in which musculoskeletal involvement remains common. Spinal tuberculosis may be suspected on a chest X-ray as in this case. The dorsolumbar region is the most commonly affected. Prominent bone destruction involving several adjacent vertebral bodies, intervertebral disc destruction, formation of paravertebral abscesses and skip lesions are important radiological features. The paravertebral abscesses may calcify, resulting in cord compression and myelopathic damage.
FURTHER READING
- Al-Mulhim FA, Ibrahim EM, El-Hassan AY, Moharram HM. Magnetic resonance imaging of tuberculous spondylitis. Spine. 1995;20(21):2287–92.
- Harada Y, Tokuda O, Matsunaga M. Magnetic resonance imaging characteristics of tuberculous spondylitis vs pyogenic spondylitis. Clin Imaging. 2008;32(4):303–9.
CASE 7
A 42-year-old male living with AIDS presented with cough, fever and weight loss. A chest X-ray done on the day of admission is shown.
DISCUSSION
In an AIDS patient, the diagnostic possibilities are Pneumocystis jiroveci pneumonia, tuberculosis, including Mycobacterium avium complex, Kaposi sarcoma, non-Hodgkins lymphoma and fungal infections. In a nonimmunocompromised patient, the differential diagnosis will include Wegener's granulomatosis, rheumatoid arthritis (Caplan's syndrome), sarcoidosis, hydatid disease and necrotizing pneumonia, e.g. Klebsiella pneumoniae.
FURTHER READING
- Allen CM, Al-Jahdali HH, Irion KL, et al. Imaging lung manifestations of HIV/AIDS. Ann Thorac Med. 2010;5(4):201–16.
- Lillington GA, Caskey CI. Evaluation and management of solitary and multiple pulmonary nodules. Clin Chest Med. 1993;14:111–9.
CASE 8
A 55-year-old man presented with progressive right upper limb weakness and slurred speech.
Figure 1: Chest X-ray showed bilateral ground-glass bats-wing opacities, which were confirmed by the CT images (Figs 2A and B)
Figure 3: Diffusion-weighted brain MR images show a left parietal hyperintense rounded lesion and multiple small hyperintense, including some ring lesions in the white matter. They show no edema. The ventricles and cisterns are normal
DISCUSSION
The bilateral bats-wing ground-glass opacities strongly suggest Pneumocystis jiroveci pneumonia. Hematological examination confirmed HIV infection. The lesions in the brain demonstrated by MRI may represent metastatic disease, infections such as tuberculosis or toxoplasmosis or lymphoma. In an AIDS patient, toxoplasmosis or lymphoma are the most likely possibilities. HIV infection is one of the major causes of mortality and morbidity, especially in sub-Saharan Africa, where because of inadequate treatment facilities, the problem remains significant.
FURTHER READING
- Burrill J, Williams CJ, Bain G, et al. Tuberculosis: A Radiologic Review. Radiographics. 2007;27:1155–273.
- McGuinness G. Changing trends in the pulmonary manifestations of AIDS. Radiol Clin North Am. 1997;35:1029–82.
CASE 9
A 23-year-old man presented at the emergency unit with chest pain and difficulty in breathing of one-week duration, and a one month history of fever, productive cough and weight loss.
Figures 1A and B: (A) Chest radiograph at presentation showing an opaque left hemithorax, air-bronchogram and mediastinal shift to the left. Streaky opacities are noted in the right upper and middle zones, with compensatory hyperinflation of the right lung; (B) Closeup of the left upper zone shows better demonstration of the air-bronchogram, indicative of upper lobe consolidation. Note the obliteration of the left cardiac outline
Figure 2: Left chest ultrasound to assess any pleural fluid shows streaky hyperechoic shadows from airfilled bronchi in the consolidated lung
Figure 3: After 13 months of anti-TB treatment, there is a near complete resolution of the radiological changes. Note residual left basal pneumatoceles(Courtesy: Dr Adekunle Abdulkadir)
DISCUSSION
Pulmonary tuberculosis (PTB) is a common lung infection affecting approximately two billion people worldwide. Approximately 2 million deaths are reported annually from TB. Pulmonary consolidation from PTB is commonly limited to the middle or lower lobes or the anterior segment of an upper lobe. Whole lung consolidation with extensive air bronchogram, as in this patient, is a rare presentation in PTB. The broad spectrum of radiographic findings in PTB include consolidation, cavitation, pneumatocele, segmental or lobar atelectasis, pleural effusion, hilar, mediastinal lymphadenopathy, miliary nodules. A normal chest radiograph may be seen in about 15% of patients.
Computed tomography (CT) is occasionally useful for clarifying confusing findings but has not been conclusively shown to have a significant impact on patient management.
Ultrasound has found use in the guidance of needle aspiration for establishing etiologic diagnosis in atypical cases. A heterogeneous iso-echoic density with interspaced echogenic structures (air-bronchogram) are reported classic ultrasonographic findings in lung consolidation or atelectasis.
FURTHER READING
- Andreu J, Caceres J, Pallisa E, Martinez-Rodriguez M. Radiological manifestations of pulmonary tuberculosis. Eur J Radiol. 2004;51:139–49.
- Tsao TC, Juang YC, Tsai YH, Lan RS, Lee CH. Whole lung tuberculosis. A disease with high mortality which is frequently misdiagnosed. Chest. 1992;101:1309–11.
- Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, Melvin IG. Update: the radiographic features of pulmonary tuberculosis. AJR Am J Roentgenol. 1986;146:497–506.
CASE 10
A 41-year-old male was admitted with a history of persistent cough, fever and weight loss.
Figure 1: PA chest radiograph shows gross globular cardiomegaly, suggestive of pericardial effusion, and bilateral upper lobe pulmonary infiltrates consistent with PTB
Figure 2: Axial CT chest showing bilateral upper lobe infiltrates, fibrosis and cysts, consistent with PTB
Figure 3: Axial CT chest with mediastinal window confirms massive pericardial effusion. Sputum and pericardial fluid aspirate confirmed TB
DISCUSSION
Tuberculosis remains a worldwide problem, mainly because of the upsurge of AIDS and widespread international travel. The radiological features of both primary and postprimary TB are well-established. Pericardial involvement is not uncommon, as in this case.
FURTHER READING
- Mayosi BM, Burgess LJ, Doubell AF. Heart Disease in Africa: Tuberculous pericarditis. Circulation. 2005;112:3608–16.
CASE 11
A 37-year-old man treated for pulmonary tuberculosis several years earlier, complained of recurrent chest pain and tightness.
Figures 1A and B: Frontal chest radiograph demonstrates a thin egg-shell pericardial calcification and calcifications (arrow) in the interventricular groove. Note also the bilateral pleural fluid collection(Courtesy: Dr Adekunle Abdulkadir)
DISCUSSION
Pericardial calcification is usually preceded by a prior episode of inflammation from a variety of infections, trauma, and neoplasms. It is strongly associated with constrictive pericarditis, which occurs when there is interference with diastolic filling of the heart. The patient may present with fatigue, exertional dyspnea, cough, orthopnea, angina like chest pain, hypotension, reflex tachycardia, jugular venous distension, hepatomegaly with marked ascites, and peripheral edema. Pericardial calcification is detected in up to 50% of patients with constrictive pericarditis. Therefore, constrictive pericarditis may exist without pericardial calcification, and pericardial calcification can be present without constrictive pericarditis.
Pleural effusions are present in about 60% of patients, and persistent unexplained pleural effusions can be the presenting manifestation.
CT is the best technique to detect pericardial calcification, but overpenetrated plain films, fluoroscopy and MRI are helpful. Pericardial calcifications most commonly occur along the inferior diaphragmatic surface of the pericardium surrounding the ventricles. Pericardial calcification with thin, egg-shell calcification is more often associated with viral infection or uremia. In addition, tuberculosis causes irregular slightly coarse calcifications along the atrioventricular groove.
FURTHER READING
- Langer C, Butz T, Horstkotte D. Multimodality in imaging calcific constrictive pericarditis. Heart. 2006;92(9):1289.
- Schwefer M, Aschenbach R, Heidemann J, Mey C, Lapp H. Constrictive pericarditis, still a diagnostic challenge: comprehensive review of clinical management. Eur J Cardiothorac Surg. 2009;36:502–10.
- Sengupta PP, Eleid MF, Khandheria BK. Constrictive pericarditis. Circ. 2008;72:1555–62.
CASE 12
25A 37-year-old man presented with a 5-year history of dyspnea of increasing severity. Previous investigations included echocardiography, multidetector computerized tomography (MDCT) and cardiac MRI. A chest X-ray was done prior to readmission.
Figure 1: PA chest radiograph shows a normal sized heart, marked enlargement of the main pulmonary and central hilar arteries, marked peripheral vascular pruning and oligemic and hyperlucent lung fields
Impression: Severe pulmonary arterial hypertension, consistent with longstanding arterial septal defect (ASD) and shunt reversal (Eisenmenger's syndrome).
DISCUSSION
Echocardiography, MDCT and cardiac MRI confirmed sinus venous type ASD with bidirectional flow and pulmonary emboli. Pulmonary arterial hypertension is defined as a systolic pressure in the pulmonary artery exceeding 30 mm Hg measured directly by catheterization of the pulmonary artery or indirectly by echocardiography. The diagnosis is usually evident from the clinical history, physical findings and chest radiographic appearances. It may be primary or secondary to pulmonary venous hypertension, thrombo-embolic disease, pulmonary interstitial diseases, schistosomiasis, drugs, etc.
FURTHER READING
- Grosse C, Grosse A. CT findings in diseases associated with pulmonary hypertension: A current review. Radiographics. 2010;30:1753–77.
- Ng CS, Wells AU, Padley SP. A CT sign of chronic pulmonary arterial hypertension: The ratio of main pulmonary artery to aortic diameter. J Thorac Imag. 1999;14:270–8.
CASE 13
A 61-year-old male presented with chest pain, dyspnea, cough and hypotension. He has a previous history of swollen left leg. His chest X-ray was normal, but a V/Q scan shows a high probability of pulmonary embolism. ACT pulmonary angiogram was done.
Figure 1: Axial CT showing a saddle embolus extending across the main right and left pulmonary arteries
Figure 2: Axial image shows extension of the emboli into the lobar and segmental branches of the pulmonary arteries
DISCUSSION
Pulmonary embolism is a major cause of death. Risk factors include hypercoagulable states, pregnancy, malignancy, surgery, indwelling catheters and DVT. Investigations include Chest X-ray, ECG, echocardiography, PO2, D-dimer and V/Q scans. Definitive diagnosis is by CT angiography or catheter angiography. Pulmonary infarction and pleural effusions are not uncommonly seen.
FURTHER READING
- Backner CB, Walker CW, Pumell GL. Pulmonary embolism: Chest radiographic abnormalities. J Thorac Imag. 1989;4:23–7.
- Hansell DM, Padley SP. Continuous volume computed tomography in pulmonary embolism: The answer or just another test? Thorax. 1996;51:1–2.
CASE 14
A 32-year-old man had a routine preemployment chest radiograph. On clinical examination, he was found to be hypertensive.
Figure 1C: Figures 1A to C (A) Chest X-ray shows normal lung fields; (B) The descending aorta demonstrates a “figure 3 sign”, and there is bilateral rib notching, better demonstrated on close-up. Features are those of coarctation of the aorta; (C) CT angiogram of another patient with coarctation of the aorta. Note the pre- and poststenotic dilatation
DISCUSSION
Coarctation of aorta is a congenital narrowing which occurs in the region of the insertion of the ductus arteriosus, with 3 recognized types: preductal, ductal, and postductal. It is twice as common in males as in females, and it is associated with Turner syndrome. Bilateral inferior rib notching occurs due to the intercostal arteries in the neurovascular bundle which dilate as they act as collaterals. The “figure 3 sign” represents the prestenotic and post-stenotic dilatation of the descending aorta.
Balloon dilatation and stenting have become effective alternatives to surgical intervention in the treatment of coarctation of the aorta.
FURTHER READING
- Fawzy ME, Fathala A, et al. Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults. Am Heart J. 2008;156(5):910–7.
- Rao PS. Coarctation of the aorta. Curr Cardiol Rep. 2005;7(6):425–34.
- Silvilairat S, Cetta F, et al. Abdominal aortic pulsed wave Doppler patterns reliably reflect clinical severity in patients with coarctation of the aorta. Congenit Heart Dis. 2008;3(6):422–30.
CASE 15
A 55-year-old male diabetic hypertensive complains of shortness of breath, fatigue and cough. He has a previous history of coronary by-pass surgery.
Figure 1: PA chest radiograph on admission shows mild cardiomegaly with left ventricular configuration, congested hilar vessels with distended upper lobe veins, numerous septal lines (Kerley A and B lines), and thickened horizontal fissure. An azygos lobe and fissure as well as sternal sutures are noted
Impression: Pulmonary interstitial edema due to left ventricular failure of hypertensive origin.
DISCUSSION
Septal lines, first described by Kerley in patients with pulmonary edema represent thickened interlobular septa, the interstitial tissues that separate the secondary pulmonary lobules. B lines are short, 1–2 cm lines perpendicular to the pleural surface and parallel to one another. A lines are up to 4 cm long and radiate from the hila to the central parts of the lung. Septal lines are seen in pulmonary edema, lymphangitis carcinomatosa, pneumoconiosis, sarcoidosis, etc.
FURTHER READING
- Kerley P Radiology in heart disease. BMJ. 1933;2:594–7.
- Paterson DI, O'Meara E, Chow BJ, et al. Recent advances in cardiac imaging for patients with heart failure. Curr Opin Cardiol. 2011;26(2):132–43.
CASE 16
A 10-year-old boy presented to the accident and emergency department after a blunt injury to the chest in a motor car accident. He was in respiratory distress but hemodynamically stable, with decreased air entry on the left side and vague epigastric discomfort. A plain chest radiograph showed a large left-sided tension hydropneumothorax with a mediastinal shift to the right. No rib injury was demonstrated. A left chest tube was inserted. A repeat chest radiograph 3 days later showed mottled opacities in the left hemithorax, and a barium meal confirmed an intrathoracic stomach.
Figure 1C: Figures 1A to C (A) Erect chest radiograph about 6 hours after the chest trauma. A giant air-fluid level is present at the left base with the mediastinum shifted to the right. Note absence of the left hemidiaphragm; (B) Supine chest radiograph 3 days later showed mottled opacities in the left hemithorax that appear to have intra-abdominal extension; (C) Chest radiograph after barium meal confirmed gastric herniation into the left hemithorax. Note the gastric rugae outlined by barium(Courtesy: Dr Adekunle Abdulkadir)
Diagnosis: Diaphragmatic rupture with gastric herniation.
DISCUSSION
In post-traumatic diaphragmatic rupture, the left hemidiaphragm is affected three times more frequently than the right, possibly due to a buffering effect of the liver on the right. Wide diaphragmatic tears permit intrathoracic herniation of abdominal viscera, which if extensive can lead to disturbance of cardiorespiratory function due to compression.
Diaphragmatic rupture may be asymptomatic for months or years following trauma. Therefore, it remains a diagnostic challenge despite the use of a variety of imaging options.
Chest radiographs are recommended for all patients after major trauma. Its sensitivity in depicting diaphragmatic rupture is about 46% for left-sided ruptures and 17% for right-sided ruptures.
The fluoroscopic demonstration of absent or decreased diaphragmatic motion is suggestive of diaphragmatic injury. The diagnosis of herniated viscera can be confirmed by barium studies.
Ultrasonography makes a limited contribution, but may depict large defects with herniation of intra-abdominal viscera. Peristaltic bowel loops may be identified as passing upward into the thorax, although intraluminal bowel gas may obscure the diaphragm.
CT is the imaging modality of choice in the evaluation of severe blunt thoracoabdominal trauma. The CT signs of diaphragmatic rupture include discontinuity of the diaphragm, visceral herniation, and a waist-like constriction (collar sign) produced by diaphragmatic compression of herniated organs.33 On CT, congenital posterolateral defect (Bochdalek hernia), may mimic diaphragmatic rupture.
MRI with breath-hold acquisition permits good visualization of diaphragmatic abnormalities, however, this technique is difficult to perform in the patient involved in polytrauma.
FURTHER READING
- Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: Spectrum of radiographic findings. Radiographics. 1998;18(1):49–59.
- Van Hise ML, Primack SL, Israel RS, et al. CT in blunt chest trauma: Indications and limitations. Radiographics. 1998;18:1071–84.
CASE 17
A 19-year-old man was brought into the emergency room with chest injuries sustained in a high velocity motor vehicle accident. The right chest showed abrasions, with a suspicion of underlying rib injury. CT done showed pnuemothorax.
A thoracostomy tube was inserted, and the patient made a full recovery, with only minimal residual pulmonary scarring and pleural thickening.
Figure 1: Axial CT with lung window shows a large right tension pneumothorax, with several lacerations, contusion and atelectasis of the right lung
DISCUSSION
Pulmonary laceration may result from penetrating chest trauma, from shear stress, or from penetrating rib fractures. Fortunately, lacerations well-managed with chest tube insertion, as in this patient, recover with minimal sequelae. Possible complications include bronchopleural fistula and lung abscess.
FURTHER READING
- Gavelli G, Canini R, Bertaccini P. Traumatic injuries: Imaging of thoracic injuries. Eur Radiol. 2002;12(6):1273–94.
- Nishiumi N, Imakuchi S, et al. Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma. Ann Thorac Surg. 2010;896:232–8.
- Omert L, Yeany WW, Protetch J. Efficiency of thoracic computerized tomography in blunt chest trauma. Am Surg. 2001;67(7):660–4.
CASE 18
A 29-year-old man had a screening chest X-ray due to a residency visa processing requirement. He was symptom-free and physical examination was normal.
Figure 1: The frontal chest radiograph shows a large, well-defined soft tissue mass in the right lower mediastinum, producing a double contour to the right cardiac border and causing widening of the carina, suggestive of an enlarged left atrium
Figure 2: A barium swallow fails to show evidence of esophageal compression expected in left atrial enlargement
Figures 3A and B: CT images confirm a large bronchogenic cyst in the posterior mediastinum, with splaying of the carina
DISCUSSION
Bronchogenic cysts are the most common congenital intrathoracic cysts. Most occur in the middle mediastinum, but some are seen in the posterior mediastinum. Most occur near the carina and may coexist with bronchial atresia and pericardial defects. Intrapulmonary cysts may be large and show air-fluid levels. MRI shows the cyst well in additional planes.
FURTHER READING
- Erasmus JJ, McAdams HP, Donelly LF, Spritzer CE. MR imaging of mediastinal masses. Magn Reson Imaging Clin North Am. 2000;8:59–89.
- McAdams HP, Kirejczyk WM, Rosadode-Christenson ML, Matsumoto S. Bronchogenic cysts: Imaging features with clinical and histopathologic correlation. Radiology. 2000;217:441–6.
CASE 19
A morbidly obese 57-year-old female presented with severe shortness of breath, lethargy and cyanosis. She had pedal edema and basal crepitations. This prompted a suspicion of cardiac failure.
Figure 1: A penetrated PA chest radiograph shows marked widening of the mediastinum. The aorta is identified, but the cardiac borders and costophrenic angles are obliterated. The trachea is relatively central and is not compressed. The pulmonary vascularity is within normal
Figures 2B and C: Figures 2A to C CT images show normal cardiac and vascular structures and excessive fat deposition in the mediastinum
DISCUSSION
Mediastinal lipomatosis results in mediastinal widening when associated with generalized obesity, as in this patient. It may, however, be seen in patients on steroid therapy and with Cushing's disease in which unencapsulated fat may be deposited in other sites. In mediastinal lipomatosis, there is usually no mass effect on the trachea and other mediastinal structures. The differential diagnosis includes neoplasms of fat tissue (lipoma, liposarcoma, lipoblastoma etc.), and Madelung's disease in which multiple masses of benign fatty tissue proliferate at various sites including the mediastinum.
FURTHER READING
- Gaerte SC, Meyer CA, Winer-Muram HT, et al. Fat-containing lesions of the chest. Radiographics. 2002;22:61–78.
CASE 20
A 45-year-old man presented with chronic productive cough and occasional hemoptysis.
Figure 1: Chest X-ray film shows hyperinflated lungs with multiple cystic areas in the bases, best appreciated over the cardiac shadow. The cardiac size and shape are normal
Figures 2B and C: Figures 2A to C Axial, coronal, and sagittal reformatted CT images showing multiple cystic bronchiectasis, most severe in the lower lobes
DISCUSSION
Bronchiectasis is a pathological dilatation of medium sized bronchi. Its causes may be grouped as:
- Congenital: Congenital cystic bronchiectasis, associated with cystic fibrosis
- Postinfective: Staph. aureus, Klebsiella, Aspergillosis, TB
- Obstructive: Foreign bodies, malignancy.
Three types of bronchiectasis are described: cylindrical, cystic (or saccular), and varicose.
In many cases, bronchiectasis may not be recognized on regular chest radiographs. High resolution CT is the imaging modality of choice in defining the location and extent of the disease.
FURTHER READING
- Barker AF. Bronchiectasis. N Engl J Med. 2002;346(18):1383–93.
- Cantin L, Bankier AA, Eisenberg RL. Bronchiectasis. Am J Roentgenol. 2009;193(3):158–71.
CASE 21
A 53-year-old man, known smoker, presented with cough, fever, and left chest pain of three weeks duration. After investigation, he was placed on antibiotics and had a good initial response, but discharged himself against medical advice and was lost to follow-up.
Figure 1: Chest radiograph shows a cavitating lesion overlying the left cardiac margin, with an air-fluid level. It is surrounded by patchy pulmonary infiltrates. The cardiac size and shape are normal. No associated mediastinal lymphadenopathy
Figures 2B and C: Figures 2A to C Axial CT chest with sagittal and coronal reformatted images. The cavity shows thick and irregular walls, with surrounding infiltrates. Features are those of a lung abscess, but a cavitating bronchogenic carcinoma is a differential
DISCUSSION
Causes of pulmonary cavitation are varied and may be classified as follows:
- Infective: Pyogenic abscess, TB
- Neoplastic: Bronchogenic carcinoma (Ca) (especially squamous cell Ca)
- Miscellaneous: Pulmonary infarction, sarcoidosis, traumatic pulmonary laceration.
This case was diagnosed as a lung abscess, but the irregular outline of the inner cavity wall is more typical of neoplasm, although this is not invariable. Also, thin-walled cavities may occasionally be present in bronchogenic carcinoma from severe necrosis.
CT is particularly sensitive in defining any mediastinal lymph nodes or pulmonary nodules elsewhere, both of which were absent in this patient.
Treatment of lung abscess is by prolonged use of antibiotics, percutaneous catheter drainage, lobectomy or pneumonectomy.
FURTHER READING
- Hern F, Ernst A, Becker HD. Endoscopic drainage of lung abscesses. Chest. 2005;147(4):1378–81.
- Kunst H, Mack D. Kon OM, et al. Parasitic infections of the lung: A guide for the respiratory physician. Thorax. 2011;66:528–36.
- Patz Jr EF. Imaging bronchogenic carcinoma. Chest. 2001;117(4):905–55.
CASE 22
An 8-year-old boy presented with a one week history of cough and dyspnea. He denied any history of foreign body inhalation.
The tip of a ballpoint pen was removed at bronchoscopy, and the patient made full recovery.
Figure 1: Chest radiograph shows an opaque left hemithorax with mediastinal shift to the left and compensatory emphysema of the right lung
Figure 2B: Figures 2A and B Axial and coronal reformatted CT chest showing a foreign body (arrows) occluding the left main stem bronchus, producing total collapse of the left lung with an air-bronchogram
CASE 23
A 6-year-old boy was brought with complaints of a one day history of severe dyspnea. He denied a history of foreign body inhalation.
Figures 1A and B: Frontal and lateral chest radiographs showing a metallic screw lodged in the right lower lobe bronchus. The screw was successfully retrieved at brochoscopy with excellent result
DISCUSSION
Foreign body inhalation is far more common in children because of their tendency to put objects in their mouth. The objects may be radiopaque or radiolucent (e.g. peanuts and plastic). Patients may present acutely with dyspnea, wheezing and choking, but hours or weeks later, they may become asymptomatic. Some patients present later still with complications, such as atelectasis, pneumonia, and abscess.
In the older child who can cooperate, chest X-ray exposures taken at inspiration and expiration may show poor air entry and exit from the affected side. As in Case 22, CT is invaluable in the diagnosis of airway foreign bodies. CT virtual bronchoscopy has also been found useful. With specific reference to inhaled peanuts, MRI has been used to advantage in locating them because of their fat content.
FURTHER READING
- Adaletli I, Kurugoglu S, Ulus S, et al. Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration. Pediatr Radiol. 2009;37:33–40.
- Cohen S, Avital A, Godfrey S, et al. Suspected foreign body inhalation in children: What are the implications of bronchoscopy? J Pediatr. 2009;155(2):276–80.
- Imaizumi H, Kaneko M. Nara S, et al. Definitive diagnosis and location of peanuts in the airways using magnetic resonance imaging techniques. Ann Emerg Med. 1994;23(6):1379–82.
CASE 24
A 59-year-old woman presented with cough, hemoptysis, chest pain and weight loss.
Figure 1C: Figures 1A to C CT chest with coronal reformatted and axial images showing a large mass in the right upper lobe with irregular, lobulated outlines. There is a pleural tail extending to the lateral chest wall and to the mediastinum. Wide-spread nodular opacities are noted in both lungs. Features are highly suggestive of bronchogenic carcinoma with extensive metastases
DISCUSSION
Bronchogenic carcinoma is the most common cancer in men in the United States and the 6th most common in women. It accounts for 20% of all cancer deaths worldwide. Cigarrete smoking is implicated in 90% of cases.
The most common sites of metastases include hilar/mediastinal lymph nodes, brain, bone, liver, adrenals and the contralateral lung. The pattern of distribution of the pulmonary nodules in this patient probably represents hematogenous spread.
FURTHER READING
- Fauci AS, Braunwald E, Kasper DL, et al. Harrison's Principles of Internal Medicine. McGraw-Hill Professional. 2008; ISBN:0071466339.
CASE 25
An 8-year-old female complained of cough, shortness of breath, and poor appetite. She was mildly febrile and had hepatosplenomegaly and cervical lymphadenopathy.
Figure 1: Frontal chest X-ray shows enormous bilateral mediastinal soft tissue masses. The trachea remains central
Figure 2B: Figures 2A and B The contrast-enhanced CT chest images show a large anterior mediastinal mass of homogenous density extending to the middle and posterior mediastinum and encasing the major vessels, trachea and main bronchi. There are no pulmonary or pleural lesions. Other findings included hepatomegaly, massive splenomegaly and peritoneal effusion
Diagnosis: Lymphoma or acute lymphoblastic leukemia. Hematological investigations confirmed the latter.
DISCUSSION
Lymph node enlargement is seen in some cases of leukemia, the pattern being the same as with lymphoma. The lymph node enlargement in both may resolve remarkably rapidly with therapy. T-cell leukemias may show massive mediastinal lymphadenopathy that responds rapidly to chemotherapy or radiation treatment, as occurred in this case.
FURTHER READING
- Felson B. The lymphomas and leukaemias–Part 1. Semin Roentgenol. 1980;15(3).
- Felson B. The lymphomas and leukaemias–Part 2. Semin Roentgenol. 1980;15(3).
CASE 26
A 51-year-old man complained of left-sided chest pain radiating to the infrascapular region for two months. Physical examination was normal.
Figure 1: A PA chest X-ray revealed an ovoid well-defined and slightly lobulated opacity in the left midzone near the hilum. There is associated osteolytic destruction of the posterior ends of the left 7th and 8th ribs in relation to the mass
Figure 2: Axial CT images identified a well-defined posterior mediastinal mass with multiple calcific foci, destruction of the adjacent rib and vertebra with extension into the spinal canal, consistent with a neurogenic tumor
DISCUSSION
Most neurogenic tumors (neurofibromas, schwanommas, ganglioneuromas, ganglioneuroblastomas, etc.) manifest as well-defined masses with smooth or lobulated outlines. Most are spherical and located in the posterior mediastinum. Distinction between benign and malignant tumors may be difficult based on imaging features. Calcification is seen in all types. They may be homogenous or of mixed attenuation on plain CT and may show cystic degeneration. Enhancement patterns are variable—homogenous or heterogenous, rim or target patterns. MR signal intensity patterns are variable, but spinal and intraspinal involvements are better demonstrated.
FURTHER READING
- Lee JY, Lee KS, Han J, et al. Spectrum of neurogenic tumors in the thorax: CT and pathologic findings. J Comput Assist Tomogr. 1999;23:399–406.
- Pilavaki M, Chourmouze D, Kizirdou A, et al. Imaging of peripheral nerve sheath tumors with pathologic correlation. Pictorial review. Eur J Radiol. 2004;52:229–39.
CASE 27
A 38-year-old man had a routine pre-employment chest X-ray.
Figure 1: Chest radiograph showing opacity of the left apex. The rest of the lung fields and the cardiac size and shape are normal
Figure 3: Left parasagittal reformatted image showing a superior mediastinal mass extending from the thoracic inlet, with a smooth inferior margin. Attenuation coefficient was −100 Hounsfield units, consistent with fat
Diagnosis: Superior mediastinal lipoma.
DISCUSSION
Intrathoracic lipomas are rare and usually discovered incidentally during routine chest radiographs. They are usually symptomless, but when they occur, symptoms depend on their size and location. Giant lipomas may cause dyspnea, whereas bronchial lipomas may produce bronchial occlusion or hemoptysis.
The differential diagnosis of superior mediastinal lipoma includes thymolipoma, harmatoma, and liposarcoma. In the management of intrathoracic lipomas, surgical resection is advocated, as liposarcoma needs to be excluded.
FURTHER READING
- Gaerte SC, Meyer CA, Winer-Muram HT, et al. Fat-containing lesions of the chest. Radiographics. 2002;22:S61–S78.
- Karlo CA, Stolzmann P, Fravenfelder T, et al. Computed tomography imaging of subpleural lipoma in two men: Two case reports. J Med Case Reports. 2010;4:380.
- Kransdorf MJ, Bancroft LW, Peterson JJ, et al. Imaging of fatty tumors: Distinction of lipoma and well-differentiated liposarcoma. Radiology. 2002;224:99–104.
CASE 28
A 53-year-old man presented to the emergency room with a history of chronic pain in both shoulders. X-rays of both shoulders were done. Incidental finding of elevated left dome of diaphragm was seen and a chest radiograph was done. Detailed clinical history revealed no significant chest symptoms, and there was no history of previous trauma or chest surgery.
Fluoroscopy displayed poor excursion of left dome of diaphragm with respiration.
Figure 1: Posteroanterior chest radiograph shows marked elevation of an intact left dome of diaphragm with fundal gas and colonic gas shadows high in the left chest. There is also marked mediastinal and tracheal shift to the right
Figure 2B: Figures 2A and B (A) Axial CT chest mediastinal window and lung window; (B) At mid chest level show stomach and bowel loops in the left chest(Courtesy: Dr Sujatha Rajkumar)
Diagnosis: Congenital unilateral eventration of the diaphragm in an adult.
DISCUSSION
Unilateral elevation of hemidiaphragm may be secondary to adjacent pulmonary, pleural or subphrenic pathology, phrenic nerve palsy or trauma.
Congenital eventration of the diaphragm is due to a thin, hypoplastic but intact diaphragm with displacement of abdominal contents into thorax. It has a right-sided predominance of 5:1, being anteromedial on the right and total involvement on the left. Left-sided eventration is indistinguishable from diaphragmatic paralysis on radiographs, which may be due to surgery, neoplastic infiltration or idiopathic phrenic nerve dysfunction due to viral neuritis.
Chronic loss of lung volume due to collapse or lobectomy may cause elevated diaphragmatic dome. Splenomegaly, gaseous distension of stomach/splenic flexure of colon, subpulmonic pleural effusion or large tumor adjacent to the dome are other causes of unilateral elevation of the dome of diaphragm.
FURTHER READING
- Brant WE, Helms CA. Fundamentals of Diagnostic Radiology, 3rd edition, Lippincott Williams & Wilkins, Philadelphia; 2007. pp. 547–8.
- Dahnert W. Radiology Review Manual, 7th edition, Chest Disorders, Lippincott Williams & Wilkins, Philadelphia; 2011. p. 499.
CASE 29
A 23-year-old male was referred for a chest X-ray because of increasing shortness of breath and fatigue.
Physical examination and echocardiography confirmed the diagnosis of atrial septal defect (ASD).
Figure 1: Posteroanterior chest radiograph shows mild cardiomegaly, enlarged right atrium and large central and peripheral pulmonary arteries. The upper zone vessels are prominent. There are no changes of pulmonary edema
DISCUSSION
The types of ASD are ostium primum, ostium secundum, sinus venosus and anomalous pulmonary veins. ASDs are the most common congenital heart defects in adults. Ostium secondum defects form about 80% of all ASDs and are located in the fossa ovalis. The sinus venosus defect is rare and is often associated with partial anomalous pulmonary venous drainage. Evaluation of ASDs involves establishment of the type and location of the defect, quantification of the shunt, assessment of right ventricular function and pulmonary venous anatomy and detection of any intra-atrial thrombus. Management is with transcatheter ASD mechanical closure or by open heart surgery.
FURTHER READING
- Gatzoulis MA, Webb GA, Daudency P. Diagnosis and management of adult congenital heart disease. Churchill Livingstone, London; 2003.
CASE 30
A 58-year-old male presents with cough and progressive shortness of breath.
Figure 1C: Figures 1A to C HRCT images show that the abnormalities are predominantly subpleural and bibasal, and comprise a reticular pattern within which there are areas of honey-combing and traction bronchiectasis. The pattern is that of idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP). Areas of ground glass opacity are shown
DISCUSSION
Usual interstitial pneumonia is the most common histopathological pattern in patients presenting as cryptogenic fibrosing alveolitis/IPF. Other causes of UIP-type pattern include chronic hypersensitivity pneumonitis, connective tissue diseases and certain drugs, e.g. nitrofurantoin. The chest radiograph shows bilateral asymmetric peripheral reticular opacities, most marked in the lung bases, with volume loss. As the disease advances, it creeps around the periphery of the lungs to involve the upper lobes. Complications of UIP include Pneumocystis jiroveci pneumonia, carcinoma and pulmonary TB.
FURTHER READING
- Johkoh T, Muller NI, Cartier Y, et al. Idiopathic interstitial pneumonia: Diagnostic accuracy of thin section CT in 129 patients. Radiology. 1999;211:555–60.
- Muller NI. Clinical value of high resolution CT in chronic diffuse lung disease. AJR Am J Roentgenol. 1991;157:1163–70.
CASE 31
A 40-year-old man presents with mild shortness of breath. A chest radiograph shows bilateral parenchymal nodular opacities.
Figure 1C: Figures 1A to C HRCT images show extensive nodular opacities which have become confluent and are predominantly subpleural and along neurovascular bundles, with cystic areas and interlobular septa thickening. Nodules are shown in the fissures giving them a beaded appearance. The findings are consistent with stage III sarcoidosis. The fissural nodules are a useful clue to the diagnois. This HRCT appearance is similar to the crazy-paving seen in pulmonary alveolar proteinosis
DISCUSSION
Sarcoidosis is a multisystem granulomatous disorder of young adults. The hilar and mediastinal lymph nodes and the lungs are affected much more than any other organ. The skin, eyes, spleen, CNS, parotids and bones may be involved. Lymphadenopathy occurs in 70–80% of cases. Remaining parenchymal changes which may lead to fibrosis account for most of the morbidity and mortality.
FURTHER READING
- Brauner MW, Grenier P, Mompoint D, et al. Pulmonary sarcoidosis: Evaluation with high resolution CT. Radiology. 1989;172:467–71.
- Criado E, Sanchez M, Ramirez J, et al. Pulmonary sarcoidosis: Typical and Atypical manifestations at high resolution CT with pathologic correlation. Radiographics. 2010;30:1567–86.
- Hamper UM, Fishman EK, Khouri NF, et al. Typical and atypical CT manifestations of pulmonary sarcoidosis. J Comput Asst Tomogr. 1986;10:928–36.
CASE 32
A 22-year-old man presented to emergency with one episode of hemoptysis and was sent to the radiology department for chest X-ray to rule out tuberculosis.
Figure 1: Erect frontal chest radiograph shows three large sharply-defined opacities with lobulated outline in right hilar and lower zone and left paracardiac regions. Coiled tubular shadows are seen within the masses and from the mass to the hilum. No calcifications are seen
Figure 2B: Figures 2A and B Plain axial and sagittal reformatted, contrast-enhanced CT chest images show the well-circumscribed, lobulated noncalcified masses connected by blood vessels, the feeding and draining vessels being clearly seen. The features are those of pulmonary arteriovenous malformations (PAVM)(Courtesy: Dr Sujatha Rajkumar)
DISCUSSION
Pulmonary arteriovenous malformations are rare pulmonary vascular anomalies with abnormal communication between the pulmonary artery and the pulmonary vein (95%) or systemic artery and pulmonary vein (5%). PAVMs are usually congenital in origin; however, they may be acquired in a variety of conditions, such as hepatic cirrhosis, schistosomiasis, mitral stenosis, trauma, actinomycosis, metastatic thyroid carcinoma and TB (Rasmussen's Aneurysm).
Although most patients are asymptomatic, PAVMs can cause dyspnea from right-to-left shunt. Because of paradoxical emboli, various central nervous system complications have been described including stroke and brain abscess. There is a strong association between PAVM and hereditary hemorrhagic telangiectasia and screening of first degree relatives is recommended.
Chest radiography and contrast-enhanced computed tomography are essential initial diagnostic tools, but pulmonary angiography is the gold standard. Although pulmonary angiography is for confirmation of a PAVM, angiography is required only when further intervention is planned.
Therapeutic options include angiographic embolization with metal coil or balloon occlusion and surgical excision.
FURTHER READING
- Dahnert W. Radiology review manual, 7th edition. Chest Disorders, Lippincott Williams and Wilkins, New Delhi; 2011. p. 531.
- Hansell DM, Lynch DA, McAdams HP, et al. Imaging diseases of the chest, 5th edition, Chapter 16. Congenital disorders of the lung and airways. Elsevier Ltd.; 2009. pp. 1079–86.
CASE 33
An asymptomatic 37-year-old man had a chest radiograph for pre-employment assessment.
Figure 1: PA chest radiograph shows multiple cystic shadows of varying sizes occupying the right hemithorax. The trachea and heart are markedly shifted to the right, and the left lung shows compensatory emphysema. Note the flattened left hemidiaphragm. Impression: The features are those of cystic adenomatoid malformation of the right lung presenting in an adult
Figure 2: Coronal reformatted CT image showing the multiple deformed cysts, some communicating with each other
Figures 3A and B: Axial and right parasagittal reformatted images show the anomalous right lung posterior to the heart and the emphysematous left lung crossing the mid-line to lie anterior to the heart
Figure 5: Mediastinal window shows the heart displaced against the right chest wall. Note the right paravertebral location of the descending aorta
DISCUSSION
Cystic adenomatoid malformation (CAM) is believed to result from a developmental error at or before the 7th week of intrauterine life, in which there is an adenomatous proliferation of the terminal bronchioles and cystic distortion of the lung parenchyma. Most cases of CAM are diagnosed prenatally by ultrasonography or by the age of 5 years, with affected children presenting with neonatal respiratory distress or recurrent chest infection. Presentation in the adult is extremely rare.
CAM is classified into 3 types: Type 1 with large cysts (2–10 cm), Type 2 with small cysts (0.5–2 cm), and Type 3 with microscopic cysts (macroscopically solid).
Surgical resection is the treatment of choice for CAM, to avert complications, such as hemorrhage, recurrent infection and malignancy.
FURTHER READING
- Avitabile AM, Greco MA, Hulnick DH, Feiner HD. Congenital cystic adenomatoid malformation of the lung in adults. Am J Surg Pathol. 1984;8(3):193–202.
- Davies AR, Bapat V, Treasure T. Adult presentation of congenital cystic adenomatoid malformation: Successful surgical management. J Thorac Cardiovasc Surg. 2006;132:1493–4.
- Han YM, Lee DK, Lee SY, et al. Adult presentation of congenital cystic adenomatoid malformation of the lung; A Case Report. J Korean Med Sci. 1994;9:86–91.
- Lujan M, Bosque M, Mirapeix RM, et al. Late-onset congenital cystic adenomatoid malformation of the lung: Embryology, Clinical symptomatology, diagnostic procedures, therapeutic approach and clinical follow-up. Respiration. 2002;69(2):148–54.