Chest Radiology Practice Questions

Q: A CT pulmonary angiogram shows intravascular webs and bands. Which additional finding would best support chronic pulmonary embolism?

Mosaic perfusion. ***Mosaic perfusion*** - **Mosaic perfusion** on CT is a characteristic sign of **chronic pulmonary embolism (CPE)**, indicating areas of differentially perfused and attenuated lung parenchyma due to chronic vascular obstruction. - This finding, combined with **intravascular webs and bands** (representing organized chronic thrombus), strongly supports the diagnosis of CPE. - Together, these constitute hallmark CT findings of chronic thromboembolic pulmonary hypertension (CTEPH). *Hampton's hump* - **Hampton's hump** is a pleura-based, wedge-shaped opacity representing **pulmonary infarction**, typically associated with **acute PE**. - While suggestive of PE, it is specific for acute disease and does not indicate chronic vascular changes or remodeling. *Westermark sign* - The **Westermark sign** is focal oligemia (decreased vascular markings) distal to a pulmonary embolism on chest X-ray, suggestive of **acute PE**. - It reflects reduced blood flow due to acute obstruction, not the chronic vascular remodeling and organized thrombus seen in CPE. *Fleischner lines* - **Fleischner lines** are horizontal linear opacities on chest X-ray, representing **atelectasis** or **subsegmental collapse**. - These are non-specific findings that can occur in various conditions and do not provide direct evidence of chronic thromboembolic disease.

Q: A lung biopsy shows 'temporal heterogeneity' with fibroblastic foci. Which radiological pattern would best support usual interstitial pneumonia?

Peripheral and basal honeycombing. ***Peripheral and basal honeycombing*** - The combination of **temporal heterogeneity** and **fibroblastic foci** on biopsy is pathognomonic for usual interstitial pneumonia (UIP). - Radiologically, UIP is characterized by **peripheral, basal, reticular opacities** with **honeycombing**, often accompanied by **traction bronchiectasis**. *Peribronchovascular nodules* - This pattern is more commonly seen in **sarcoidosis**, a granulomatous disease, rather than UIP. - Sarcoidosis involves lymphocytic inflammation and non-caseating granulomas, which is distinct from the fibrotic process of UIP. *Central ground glass opacities* - While ground-glass opacities can be seen in various interstitial lung diseases, a **central distribution** is less typical for UIP. - More commonly associated with **acute interstitial pneumonia** or **non-specific interstitial pneumonia (NSIP)**. *Upper lobe nodules* - **Upper lobe predominance** with nodules is characteristic of conditions like **silicosis**, **coal workers' pneumoconiosis**, or **hypersensitivity pneumonitis**. - UIP typically involves the **lower lobes** and presents as reticular opacities and honeycombing rather than discrete nodules.

Q: A chest X-ray shows a 'silhouette sign' with opacity obscuring the right heart border. Which lobe of the lung is most likely affected?

Right middle lobe. ***Right middle lobe*** - The **silhouette sign** occurs when two objects of similar radiographic density are in direct contact, obscuring their common border. - The **right middle lobe** is adjacent to the right heart border, so an opacity in this lobe will typically obscure the border. *Right upper lobe* - The right upper lobe is positioned superiorly and medially, meaning opacification would more likely obscure the **right paratracheal stripe** or the superior mediastinal borders. - It does not directly border the right heart, thus it would not produce a silhouette sign with the cardiac outline. *Right lower lobe* - The right lower lobe is primarily associated with obscuring the **right hemidiaphragm** when it collapses or becomes consolidated. - Although it is somewhat posterior to the heart, it usually does not directly obscure the anterior right heart border. *Left lower lobe* - The left lower lobe is on the opposite side of the chest and opacification would not affect the **right heart border**. - Consolidation here would more likely obscure the **left hemidiaphragm** or the medial part of the left cardiac silhouette in certain views.

Q: PA view of chest X-ray is given here. What is the diagnosis?

Right Pneumothorax with left tracheal shift. ***Right Pneumothorax with left tracheal shift*** - The image shows a large **radiolucency (black area) on the right side** of the chest, indicative of **air in the pleural space**, consistent with a **right-sided pneumothorax**. - The **trachea is shifted towards the left** (away from the pneumothorax), which is the **expected finding** in pneumothorax due to increased pressure in the right pleural space pushing mediastinal structures to the contralateral side. - In pneumothorax, the trachea and mediastinum shift **away from** the affected side due to the pressure effect of air accumulation in the pleural cavity. - This **contralateral tracheal deviation** is a classic radiological sign of pneumothorax and helps confirm the diagnosis. *Right Pneumothorax with right tracheal shift* - While the **right pneumothorax** is correctly identified, the tracheal shift direction is incorrect. - In pneumothorax, the trachea shifts **away from** the affected side (contralateral), not toward it (ipsilateral). - **Ipsilateral tracheal shift** would suggest volume loss (atelectasis) or lung collapse, not pneumothorax alone. *Left Pneumothorax with right tracheal shift* - The pneumothorax is clearly on the **right side**, not the left. - The radiolucency and absent lung markings are visible on the right hemithorax. - A left pneumothorax would show these findings on the left side. *Left Pneumothorax with left tracheal shift* - There is **no pneumothorax on the left side** of the chest. - The left lung shows normal vascular markings and no evidence of pleural air. - This combination would be medically implausible as it suggests pneumothorax with ipsilateral shift.

Q: A patient presented with complaints of dyspnoea. The shown X-ray is suggestive of:

Pleural effusion. ***Pleural effusion*** - The X-ray shows a significant **right-sided pleural effusion** with blunting of the costophrenic angle and a meniscus sign characteristic of fluid accumulation in the pleural space. - Key radiological features include: **homogeneous opacity** in the lower zone, **obliteration of the costophrenic angle**, and the typical **concave upper border (meniscus sign)** of fluid layering. - The presence of dyspnea with these radiological findings is consistent with pleural effusion. **Note:** While the X-ray confirms pleural effusion, **differentiating between exudative and transudative effusion requires pleural fluid analysis** (Light's criteria), not imaging alone. *Pneumothorax* - A pneumothorax would appear as a **dark, air-filled space** with a visible **visceral pleural line** where the lung has collapsed away from the chest wall. - The image clearly shows **fluid opacity** (white/grey) in the right hemithorax, not air (black). *Hydropneumothorax* - This condition involves both **fluid and air** in the pleural space, typically presenting with a **straight horizontal air-fluid level** on an erect chest X-ray. - The X-ray here shows a **curved meniscus** rather than a straight air-fluid level, indicating pure fluid without air. *Consolidation* - Consolidation (as seen in pneumonia) appears as a **homogenous opacity within the lung parenchyma**, often with **air bronchograms**. - The image shows fluid in the **pleural space** (outside the lung), **displacing the lung medially**, rather than an opacity within the lung tissue itself.

Q: Left cardiac border bulge can be seen in all, except -

Enlarged azygous vein. ***Enlarged azygous vein*** - An enlarged azygous vein typically presents as a widening of the **right paratracheal stripe** on a frontal chest X-ray, or a mass in the **right tracheobronchial angle**. - It does not project onto the **left cardiac border** and is therefore not associated with a left-sided bulge. *Coronary artery aneurysm* - A large **coronary artery aneurysm**, particularly of the left main or left anterior descending artery, can manifest as a localized bulge along the **left heart border**. - This is due to the expansion of the artery, which can project outwards from the cardiac silhouette. *Left atrial enlargement* - Severe **left atrial enlargement** can push the left ventricle inferiorly and anteriorly, causing a bulge along the **upper left cardiac border**. - On a chest X-ray, this is often seen as a **\"double density\" sign** or an outward convexity of the left atrial appendage. *Pericardial defect* - A congenital or acquired **pericardial defect**, especially on the left side, can allow the heart to herniate or shift to the left. - This displacement can lead to a visible **left cardiac bulge** due to the repositioning of cardiac chambers or structures within the chest cavity.

Q: A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?

USG. ***USG*** - **Ultrasound** is the **best first-line investigation** for detecting **pleural effusions** in children due to its **non-invasive nature**, lack of radiation exposure, and ability to detect even small effusions (as little as 5-10 mL). - It can effectively differentiate between pleural fluid and other pathologies (e.g., consolidation, masses) and guide aspiration if needed. - **Real-time bedside availability** makes it ideal for pediatric patients. *Lateral view Chest X-ray* - A lateral Chest X-ray only detects pleural effusion if the fluid volume is at least **75-100 mL**, which might miss smaller effusions. - While it can provide additional information about the lungs and mediastinum, it is not as sensitive as ultrasound for detecting small effusions. *Erect Chest X-ray PA view* - An erect Chest X-ray PA view requires a minimum of **200-300 mL of fluid** to blunt the **costophrenic angle**, potentially missing smaller effusions. - It involves **ionizing radiation**, a concern in pediatric patients, and is less sensitive than ultrasound for early detection. *Lateral decubitus view* - A lateral decubitus view is useful for confirming the presence of **free-flowing pleural fluid** and differentiating it from loculated effusions, typically after an initial effusion is suspected. - While sensitive for detecting small effusions (as little as **50 mL**), it is typically performed as a secondary investigation and involves radiation exposure, unlike ultrasound.

Q: A patient of RTA with injury over chest and limbs has low SpO2. M-mode ultrasound of right upper chest shows stratosphere sign. What is the diagnosis?

Pneumothorax. ***Pneumothorax*** - A **stratosphere sign** (also known as a barcode sign) on M-mode ultrasound indicates the absence of lung sliding, which is a key diagnostic feature of **pneumothorax**. - In a patient with chest injury and low SpO2, the presence of a **collapsed lung** due to air in the pleural space explains respiratory distress. *Cardiac tamponade* - Characterized by **fluid accumulation in the pericardial sac**, leading to impaired cardiac filling and shock. - While it can cause low SpO2 and be associated with chest trauma, the **stratosphere sign** is not a diagnostic feature of cardiac tamponade. *Hemothorax* - Involves the **accumulation of blood in the pleural space**, often following trauma, leading to respiratory compromise. - Ultrasound in hemothorax would show **anechoic or complex fluid collections** but not the stratosphere sign. *Pulmonary embolism* - A condition where a **blood clot blocks blood flow to the lungs**, causing sudden onset dyspnea and hypoxemia. - Although it causes low SpO2, pulmonary embolism is not diagnosed by chest ultrasound revealing a **stratosphere sign**.

Q: X-ray given below suggests:

Miliary TB. **Miliary TB** - The X-ray image displays a classic pattern of **diffuse, fine nodular opacities** bilaterally distributed throughout the lung fields, often described as a "**millet seed**" pattern. - This appearance is characteristic of **hematogenous dissemination of *Mycobacterium tuberculosis***, indicative of miliary tuberculosis. *Interstitial lung disease* - While interstitial lung diseases (ILDs) can present with diffuse opacities, the pattern is usually more reticular, reticulonodular, or ground-glass, rather than the predominantly **fine, uniform nodular pattern** seen here. - ILDs encompass a broad range of conditions, and while some can have a nodular component, this specific, widespread micronodular appearance primarily points away from typical ILD patterns. *Normal x-ray* - A normal chest X-ray would show **clear lung fields** without any significant opacities or abnormal patterns. - The image clearly displays widespread parenchymal abnormalities, making a normal X-ray diagnosis incorrect. *Hydropneumothorax* - **Hydropneumothorax** is characterized by the presence of both air and fluid in the pleural space, which would appear as a **fluid level** with an air-fluid interface and a collapsed lung, none of which are evident in this image. - The X-ray shows diffuse infiltrates within the lung parenchyma, not a pleural space abnormality.

Q: Chest CT shows bilateral ground-glass opacities with crazy paving pattern and preserved bronchial markings. Likely diagnosis?

Pulmonary alveolar proteinosis. ***Pulmonary alveolar proteinosis*** - The combination of **bilateral ground-glass opacities** with a **crazy paving pattern** and preserved bronchial markings is pathognomonic for pulmonary alveolar proteinosis. - The **crazy paving pattern** refers to superimposed reticular pattern on ground-glass opacity, resulting from thickening of the interlobular septa and intralobular lines, characteristic of protein and lipid accumulation in the alveoli. *ARDS* - While ARDS can cause **ground-glass opacities**, the **crazy paving pattern** is not a typical or primary feature. - ARDS is usually characterized by more diffuse and often dependent consolidation, and may lack the distinct septal thickening of crazy paving. *Pneumonia* - Pneumonia typically presents with **consolidation**, ground-glass opacities, or nodules, but it rarely exhibits the classic **crazy paving pattern**. - Bacterial pneumonia often shows **lobar or segmental consolidation**, while viral pneumonia can present with more diffuse ground-glass, but the reticular component of crazy paving is not prominent. *Edema* - Pulmonary edema can cause **ground-glass opacities** and septal thickening due to fluid accumulation. - However, the overall pattern typically seen in edema (e.g., **peribronchovascular cuffing**, dependent opacities) differs from the widespread and well-defined crazy paving seen in the image.

Question 1

A CT pulmonary angiogram shows intravascular webs and bands. Which additional finding would best support chronic pulmonary embolism?

Accepted Answer

Mosaic perfusion

Answer

Hampton's hump

Answer

Westermark sign

Answer

Fleischner lines

Question 2

A lung biopsy shows 'temporal heterogeneity' with fibroblastic foci. Which radiological pattern would best support usual interstitial pneumonia?

Accepted Answer

Peripheral and basal honeycombing

Answer

Peribronchovascular nodules

Answer

Central ground glass opacities

Answer

Upper lobe nodules

Question 3

A chest X-ray shows a 'silhouette sign' with opacity obscuring the right heart border. Which lobe of the lung is most likely affected?

Accepted Answer

Right middle lobe

Answer

Right upper lobe

Answer

Right lower lobe

Answer

Left lower lobe

Question 4

PA view of chest X-ray is given here. What is the diagnosis?

Accepted Answer

Right Pneumothorax with left tracheal shift

Answer

Left Pneumothorax with right tracheal shift

Answer

Left Pneumothorax with left tracheal shift

Answer

Right Pneumothorax with right tracheal shift

Question 5

A patient presented with complaints of dyspnoea. The shown X-ray is suggestive of:

Accepted Answer

Pleural effusion

Answer

Pneumothorax

Answer

Hydropneumothorax

Answer

Consolidation

Question 6

Left cardiac border bulge can be seen in all, except -

Accepted Answer

Enlarged azygous vein

Answer

Coronary artery aneurysm

Answer

Left atrial enlargement

Answer

Pericardial defect

Question 7

A 10yr old boy with a known case of nephrotic syndrome since 4 years on treatment brought to the pediatric OPD with chief complaint of difficulty in breathing. There is no history of fever. On examination, respiratory system was normal except slightly reduced breath sounds on right infra-axillary region. Paediatrician thinks of pleural effusion. What is next best modality of investigation to detect pleural effusion?

Accepted Answer

USG

Answer

Lateral view Chest X-ray

Answer

Erect Chest X-ray PA view

Answer

Lateral decubitus view

Question 8

A patient of RTA with injury over chest and limbs has low SpO2. M-mode ultrasound of right upper chest shows stratosphere sign. What is the diagnosis?

Accepted Answer

Pneumothorax

Answer

Cardiac tamponade

Answer

Hemothorax

Answer

Pulmonary embolism

Question 9

X-ray given below suggests:

Accepted Answer

Miliary TB

Answer

Interstitial lung disease

Answer

Normal x-ray

Answer

Hydropneumothorax

Question 10

Chest CT shows bilateral ground-glass opacities with crazy paving pattern and preserved bronchial markings. Likely diagnosis?

Accepted Answer

Pulmonary alveolar proteinosis

Answer

ARDS

Answer

Pneumonia

Answer

Edema

Chest Radiology — MCQs

Chest Radiology — MCQs

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