Chest Radiology Practice Questions

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

Pulmonary alveolar proteinosis. ***Pulmonary alveolar proteinosis*** - **Bilateral ground-glass opacities** with a **"crazy paving" pattern** (interlobular septal thickening superimposed on ground-glass opacities) are highly characteristic imaging findings for pulmonary alveolar proteinosis. - The **preserved bronchial markings** further support this diagnosis, as it indicates that the airspaces are filled with proteinaceous material without significant destruction of the bronchial tree. *Edema* - While pulmonary edema can cause **ground-glass opacities**, it typically presents with additional features such as **peribronchial cuffing**, **interlobular septal thickening** uniformly without "crazy paving," and often **cardiomegaly** or **pleural effusions**. - The "crazy paving" pattern is uncommon in pure pulmonary edema. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is characterized by widespread **ground-glass opacities** and **consolidation**, but it usually involves significant **loss of lung volume**, **air bronchograms**, and often **bronchial distortion**, rather than perfectly preserved bronchial markings. - The "crazy paving" pattern is not a primary or characteristic finding in ARDS. *Pneumonia* - **Pneumonia** often presents with **focal consolidation**, **ground-glass opacities**, or **lobar infiltrates**. - While some forms of atypical pneumonia might have ground-glass opacities, the distinct **"crazy paving" pattern** and **preserved bronchial markings** are not typical features.

Q: CT chest shows 'signet ring sign' with dilated bronchus and adjacent pulmonary artery. Which of these is LEAST likely?

Sarcoidosis. ***Sarcoidosis*** - While sarcoidosis can cause various pulmonary manifestations, **bronchiectasis with a "signet ring sign" is not a typical or primary feature**. It primarily causes **non-caseating granulomas**, often leading to lymphadenopathy and interstitial lung disease. - The disease's characteristic features are usually **hilar and mediastinal lymphadenopathy** and **pulmonary nodules or fibrosis**, not dilated bronchi. *ABPA* - **Allergic bronchopulmonary aspergillosis (ABPA)** commonly causes **bronchial obstruction and subsequent dilation**, leading to bronchiectasis that can manifest as a "signet ring sign" on CT. - It often involves **central bronchiectasis** with mucoid impaction, which is a key imaging finding in this condition. *Bronchiectasis* - **Bronchiectasis** is fundamentally defined by **permanent dilation of the bronchi**, which appears as a "signet ring sign" when a dilated bronchus is seen adjacent to a smaller accompanying pulmonary artery. - This finding is a **hallmark imaging feature** for diagnosing bronchiectasis, regardless of its underlying cause. *Cystic fibrosis* - **Cystic fibrosis** is a genetic disorder leading to thick, sticky mucus that obstructs airways and predisposes to recurrent infections, inevitably causing **widespread bronchiectasis**. - The **"signet ring sign" is a very common finding** in CT scans of patients with cystic fibrosis due to extensive bronchial dilation.

Q: Best imaging modality for acute pulmonary embolism

CT pulmonary angiogram. ***CT pulmonary angiogram*** - This is the **gold standard** imaging modality for diagnosing acute pulmonary embolism due to its high sensitivity and specificity in visualizing pulmonary arteries. - It rapidly provides detailed images of the pulmonary vasculature, allowing for direct visualization of **thrombi**. *V/Q scan* - A **V/Q scan** measures ventilation and perfusion of the lungs and is less definitive than CTPA, especially in patients with pre-existing lung disease. - It is often considered when **CTPA is contraindicated**, such as in cases of severe renal impairment or contrast allergy. *Chest X-ray* - A **chest X-ray** is generally used to rule out other causes of chest pain and shortness of breath, such as pneumonia or pneumothorax, rather than to diagnose PE directly. - It has **low sensitivity and specificity** for pulmonary embolism, as findings are often non-specific or normal even in the presence of PE. *MRI* - **Magnetic resonance angiography (MRA)** can be used, but it is typically reserved for patients who cannot undergo CTPA or V/Q scan due to contraindications like **pregnancy** or **renal failure**. - It often takes longer to perform and has lower spatial resolution compared to CTPA for pulmonary artery visualization.

Q: Which sign on chest X-ray indicates tension pneumothorax?

Mediastinal shift. ***Mediastinal shift*** - **Mediastinal shift** away from the affected side is the **most specific and critical radiographic sign** of tension pneumothorax on chest X-ray. - The progressive air accumulation under positive pressure pushes the **mediastinum** (heart, great vessels, trachea) toward the contralateral side, causing life-threatening **cardiorespiratory compromise** by impeding venous return and cardiac output. - This finding distinguishes tension pneumothorax from simple pneumothorax and mandates **immediate needle decompression**. *Flattened diaphragm* - A **flattened or depressed hemidiaphragm** can occur in tension pneumothorax due to increased intrapleural pressure pushing the diaphragm downward. - However, this sign is **non-specific** as it also occurs in simple pneumothorax, hyperinflation, COPD, and other conditions. - While supportive, it does not definitively indicate the high-pressure tension state. *Deep sulcus sign* - The **deep sulcus sign** (abnormally deep and lucent costophrenic angle) is seen on **supine chest X-rays** when air accumulates anteriorly and inferiorly in the pleural space. - This indicates pneumothorax but is **not specific for tension pneumothorax** and can be seen in simple pneumothorax. - It is position-dependent and does not indicate mediastinal compression. *All of the options* - While flattened diaphragm and deep sulcus sign **may be present** in tension pneumothorax, only **mediastinal shift** is the **definitive radiographic indicator** that distinguishes tension from simple pneumothorax. - Mediastinal shift is the key finding that reflects the pathophysiological pressure differential causing cardiovascular compromise.

Q: A 50-year-old male with hemoptysis shows cavitary lesion with air-crescent sign. Most likely diagnosis?

Aspergilloma. ***Aspergilloma*** - The presence of a **cavitary lesion** with an **air-crescent sign** (Monod sign) in a patient with hemoptysis is highly characteristic of an aspergilloma, which is a fungal ball growing within a pre-existing lung cavity. - **Hemoptysis** is a common symptom due to the erosion of vessels by the fungal ball or inflammation. *Tuberculosis* - While **cavitary lesions** can be seen in tuberculosis, the **air-crescent sign** is not typical and hemoptysis in TB is usually related to active infection or rupture of an aneurysm (Rasmussen's aneurysm). - Tuberculosis would typically show other features like **consolidation**, **lymphadenopathy**, or **miliary opacities** depending on the stage. *Granulomatosis with polyangiitis (GPA)* - GPA can cause **cavitary lung lesions** and **hemoptysis** due to parenchymal vasculitis. - However, it does not typically present with the definitive **air-crescent sign** seen with aspergilloma. GPA would also show signs of **renal involvement** and **upper airway disease**. *Lung abscess* - A lung abscess is a **pus-filled cavity** in the lung often caused by bacterial infection, appearing as a cavitary lesion in imaging. - While it can cause hemoptysis, the **air-crescent sign** is not a characteristic feature; instead, it typically shows a **thick, irregular wall** with an air-fluid level.

Q: Which finding is NOT associated with pulmonary embolism on CT angiography?

Hampton's hump. ***Hampton's hump*** - **Hampton's hump** is a **peripheral wedge-shaped opacity** representing **pulmonary infarction**, classically described as a **chest X-ray finding**, not a primary CT angiography (CTA) finding. - While the parenchymal opacity from infarction can be visualized on CT, it is **not what CTA is designed to detect**—CTA primarily visualizes the **pulmonary vasculature and intraluminal thrombi**. - Hampton's hump reflects a **consequence** of PE (tissue infarction) rather than the embolus itself, making it **NOT directly associated with PE on CTA**. *Filling defects* - **Filling defects** represent **intraluminal thrombus** within contrast-filled pulmonary arteries. - This is the **hallmark and primary diagnostic sign** of pulmonary embolism on CT angiography. - CTA is specifically performed to visualize these vascular abnormalities. *Enlarged pulmonary artery* - An **enlarged main pulmonary artery** (>29 mm) is a **secondary finding** on CTA that suggests **pulmonary hypertension**. - This can result from acute massive PE or chronic thromboembolic disease. - It is readily visualized and measured on CTA as part of PE assessment. *Oligemia* - **Oligemia (Westermark sign)** refers to **regional decreased vascularity** distal to a significant pulmonary artery obstruction. - While classically a **chest X-ray finding**, decreased vessel caliber and perfusion changes **can be appreciated on CTA**. - Unlike Hampton's hump (a parenchymal consequence), oligemia reflects the **vascular effect** of the obstruction and is thus more directly related to CTA findings.

Q: What does the 'Kerley B lines' appearance on a chest X-ray indicate?

Pulmonary edema. ***Pulmonary edema*** - **Kerley B lines** are thin, horizontal lines located peripherally in the lung fields on a chest X-ray, typically indicating the presence of **interstitial pulmonary edema**. - They represent **edematous interlobular septa** thickened by fluid, often seen in conditions like **congestive heart failure**. *Pulmonary fibrosis* - Characterized by **reticular opacities**, **honeycombing**, and **traction bronchiectasis** on a chest X-ray, which are distinct from Kerley B lines. - While both involve the interstitium, pulmonary fibrosis represents **irreversible scarring**, not acute fluid accumulation. *Pneumonia* - Typically presents as **lobar or patchy consolidation** (airspace opacities) on a chest X-ray, sometimes with air bronchograms, rather than thin linear opacities. - This condition involves inflammation and infection within the **alveoli**, leading to exudate. *Pleural effusion* - Appears as a **blunting of the costophrenic angles** and a **meniscus sign** (curvilinear shadow) on a chest X-ray, indicating fluid in the pleural space. - This is distinct from Kerley B lines, which are found within the lung parenchyma rather than the pleural space.

Q: What is the hallmark sign of acute respiratory distress syndrome (ARDS) on a chest X-ray?

Consolidation. ***Consolidation (Bilateral diffuse airspace opacities)*** - **Bilateral diffuse airspace opacities** (alveolar infiltrates/consolidation) are the hallmark findings of ARDS on chest X-ray, as defined by the Berlin criteria. - These opacities represent **alveolar flooding** due to increased capillary permeability and typically appear within 1 week of a known clinical insult. - The distribution is typically **bilateral and relatively symmetric**, not fully explained by effusions, lobar/lung collapse, or nodules. - Chest X-ray shows these as patchy or diffuse areas of increased opacity that can progress to more dense consolidation. *Ground-glass opacity* - **Ground-glass opacity** is primarily a **CT scan finding**, not reliably visible on plain chest X-rays. - This term describes increased attenuation with preserved bronchial and vascular markings, which requires the resolution of CT imaging to appreciate. - While present in ARDS on CT scans, it is not the hallmark feature on chest X-ray specifically. *Honeycombing* - **Honeycombing** refers to clustered cystic airspaces indicating **end-stage pulmonary fibrosis**. - This is a chronic finding seen in interstitial lung diseases, not in acute ARDS. - It represents irreversible architectural distortion from longstanding fibrosis. *Pleural effusion* - **Pleural effusion** may occur with ARDS but is not a defining or hallmark radiographic feature. - Small effusions can be present, but large effusions should prompt consideration of alternative diagnoses like heart failure. - The Berlin definition emphasizes that opacities should not be fully explained by effusions.

Q: What is the next imaging study recommended for evaluating a patient with suspected radiation-induced lung injury?

High-resolution computed tomography. ***High-resolution computed tomography*** - **HRCT** is the gold standard for diagnosing and assessing the extent of radiation-induced lung injury (**RILI**) due to its superior spatial resolution. - It can identify subtle interstitial changes, **ground-glass opacities**, **consolidation**, and **fibrosis** that are characteristic of RILI. *Standard chest radiograph* - A standard chest radiograph has limited sensitivity in detecting early interstitial changes or mild forms of **RILI**. - It can miss subtle findings and often shows abnormalities only in advanced stages. *Magnetic resonance imaging* - While MRI can provide functional information and assess soft tissue involvement, it has limitations in imaging lung parenchyma due to **motion artifacts** and low signal intensity from air. - Its role in the routine diagnosis of **RILI** is secondary to HRCT. *Thoracic ultrasound* - Thoracic ultrasound is useful for identifying **pleural effusions**, **pneumothorax**, and peripheral lung consolidations. - However, it has very limited penetration and is not suitable for evaluating deeper lung parenchyma or diffuse interstitial lung disease like **RILI**.

Q: What is the most common finding on a chest X-ray in a patient with congestive heart failure?

Cardiomegaly. ***Cardiomegaly*** - **Cardiomegaly**, evidenced by an increased **cardiothoracic ratio** on a chest X-ray, is a common and early indicator of chronic volume overload or structural heart disease, frequently seen in **congestive heart failure**. - It reflects ventricular dilation or hypertrophy, which are compensatory mechanisms that eventually fail in heart failure. *Pleural effusion* - While common in heart failure, **pleural effusions** usually represent a more advanced stage of fluid retention and are not the absolute most common initial or sole finding. - They occur due to increased hydrostatic pressure in the pleural capillaries, leading to fluid transudation. *Kerley B lines* - **Kerley B lines** are signs of **interstitial pulmonary edema**, indicating fluid accumulation in the lung interstitium. - While present in heart failure, particularly as the condition worsens, they are a specific sign and not as globally common as cardiomegaly, which can be seen even in early stages. *Pulmonary edema* - **Pulmonary edema** refers to fluid in the alveolar spaces, appearing as fluffy infiltrates on a chest X-ray. It signifies acute or severe decompensated heart failure. - Although highly characteristic of acute heart failure exacerbations, it is not consistently the most common finding across all stages of heart failure, especially in stable or mild cases where cardiomegaly might be the only radiological sign.

Question 1

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

Accepted Answer

Pulmonary alveolar proteinosis

Answer

Edema

Answer

ARDS

Answer

Pneumonia

Question 2

CT chest shows 'signet ring sign' with dilated bronchus and adjacent pulmonary artery. Which of these is LEAST likely?

Accepted Answer

Sarcoidosis

Answer

ABPA

Answer

Bronchiectasis

Answer

Cystic fibrosis

Question 3

Best imaging modality for acute pulmonary embolism

Accepted Answer

CT pulmonary angiogram

Answer

V/Q scan

Answer

Chest X-ray

Answer

MRI

Question 4

Which sign on chest X-ray indicates tension pneumothorax?

Accepted Answer

Mediastinal shift

Answer

Flattened diaphragm

Answer

Deep sulcus sign

Answer

All of the options

Question 5

A 50-year-old male with hemoptysis shows cavitary lesion with air-crescent sign. Most likely diagnosis?

Accepted Answer

Aspergilloma

Answer

Tuberculosis

Answer

Granulomatosis with polyangiitis (GPA)

Answer

Lung abscess

Question 6

Which finding is NOT associated with pulmonary embolism on CT angiography?

Accepted Answer

Hampton's hump

Answer

Filling defects

Answer

Enlarged pulmonary artery

Answer

Oligemia

Question 7

What does the 'Kerley B lines' appearance on a chest X-ray indicate?

Accepted Answer

Pulmonary edema

Answer

Pulmonary fibrosis

Answer

Pneumonia

Answer

Pleural effusion

Question 8

What is the hallmark sign of acute respiratory distress syndrome (ARDS) on a chest X-ray?

Accepted Answer

Consolidation

Answer

Ground-glass opacity

Answer

Honeycombing

Answer

Pleural effusion

Question 9

What is the next imaging study recommended for evaluating a patient with suspected radiation-induced lung injury?

Accepted Answer

High-resolution computed tomography

Answer

Standard chest radiograph

Answer

Magnetic resonance imaging

Answer

Thoracic ultrasound

Question 10

What is the most common finding on a chest X-ray in a patient with congestive heart failure?

Accepted Answer

Cardiomegaly

Answer

Pleural effusion

Answer

Kerley B lines

Answer

Pulmonary edema

Chest Radiology — MCQs

Chest Radiology — MCQs

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