Chest Radiology Practice Questions

Q: On chest radiology, "egg-shell calcification" is seen in:

Silicosis. ***Silicosis*** - **Egg-shell calcification** on chest radiology is a classic and highly characteristic finding in **silicosis**, particularly involving the **hilar lymph nodes**. - This pattern of calcification results from the deposition of calcium in the periphery of enlarged lymph nodes. *Asbestosis* - Asbestosis typically involves **interstitial fibrosis** and the formation of **pleural plaques**, which can be calcified, but these calcifications rarely exhibit an "egg-shell" pattern. - Pleural effusions and **malignant mesothelioma** are also associated with asbestos exposure. *Coal-worker pneumoconiosis* - This condition is characterized by **small, rounded opacities** throughout the lungs, and in its severe form (**progressive massive fibrosis**), large opacities can be seen. - While calcification can occur, it is not typically in the form of "egg-shell calcification" of lymph nodes. *Berylliosis* - Berylliosis, particularly the chronic form, presents with a **granulomatous inflammation** similar to sarcoidosis. - Radiologically, it often shows **bilateral hilar adenopathy** and **interstitial infiltrates**, but "egg-shell calcification" is not a typical feature.

Q: You are shown PA and lateral chest radiographs from a 53-year-old woman with mild dyspnea. Which one of the following is the most likely diagnosis based on the imaging?

Solitary fibrous tumor of the pleura. ***Solitary fibrous tumor of the pleura*** - A **solitary fibrous tumor of the pleura (SFTP)** typically manifests as a **well-circumscribed, lobulated mass** arising from the pleura, often seen on chest radiographs as a peripheral lesion. - The patient's mild dyspnea and isolated, well-defined pleural mass without other signs of widespread disease on imaging are characteristic of SFTP. *Parapneumonic effusion* - A **parapneumonic effusion** is a collection of fluid in the **pleural space** secondary to pneumonia, which would typically present as a diffuse fluid collection rather than a solid mass. - While it can cause dyspnea, imaging would show **blunting of costophrenic angles** and a **fluid level**, not a distinct mass. *Lung cancer* - **Lung cancer** could present as a solitary mass, but a **solitary fibrous tumor of the pleura** is specifically characterized by its pleural origin and typical growth pattern, which is usually benign or low-grade malignant. - A primary lung cancer would likely raise suspicion for **parenchymal involvement** or **hilar enlargement**, which are not indicated as primary features from the description of a pleural mass. *Malignant pleural mesothelioma* - **Malignant pleural mesothelioma** is usually associated with a history of **asbestos exposure** and appears as a **diffuse, irregular pleural thickening** that encases the lung, rather than a well-defined solitary mass. - This condition is aggressive and typically presents with more severe and progressive symptoms, including significant dyspnea and chest pain.

Q: Investigation of choice in bronchiectasis?

HRCT. ***HRCT*** - **High-resolution computed tomography (HRCT)** is the gold standard for diagnosing bronchiectasis, as it provides detailed images of the bronchial tree. - It effectively visualizes the characteristic **bronchial dilation**, **lack of bronchial tapering**, and **"signet-ring" appearance** of the airways. *MRI* - **Magnetic resonance imaging (MRI)** is generally not the primary imaging modality for bronchiectasis due to its lower spatial resolution compared to CT for lung parenchyma. - While it can provide functional information, it is not as effective in visualizing the characteristic anatomical changes of bronchiectasis. *Bronchoscopy* - **Bronchoscopy** is an invasive procedure primarily used to identify the cause of bronchiectasis (e.g., foreign body, infection, endobronchial obstruction) or for therapeutic lavage. - It is not the initial diagnostic investigation of choice for confirming the presence and extent of bronchiectasis itself. *Chest X-ray* - A **chest X-ray** may show non-specific findings such as increased bronchial wall opacity or tram-track lucencies, which are suggestive of bronchiectasis but not definitive. - It lacks the sensitivity and specificity of HRCT to confirm the diagnosis and delineate the extent of the disease.

Q: Miliary shadow in a chest X-ray is typically seen in all of the following conditions except:

Klebsiella. ***Klebsiella*** - **Klebsiella pneumoniae** causes *lobar pneumonia* with **dense consolidation**, often with **bulging fissures** and **cavitation**, NOT miliary shadowing. - Miliary shadows represent diffuse small (1-5 mm) nodules from **hematogenous dissemination** or **granulomatous disease**, which is NOT the pattern seen in Klebsiella pneumonia. *TB* - **Miliary tuberculosis** is the *classic cause* of miliary shadows on chest X-ray. - Results from **hematogenous dissemination** of *Mycobacterium tuberculosis*, producing countless small (1-5 mm) nodules uniformly distributed throughout both lung fields. *Sarcoidosis* - Can present with **micronodular/miliary patterns** due to widespread *non-caseating granulomas* in lung parenchyma. - The diffuse nodular infiltrative pattern can mimic miliary tuberculosis. *Metastasis* - **Miliary metastases** from thyroid, renal, melanoma, or other cancers spread hematogenously to lungs. - Produce numerous small, uniformly sized nodules creating *miliary shadows* from diffuse tumor seeding throughout pulmonary vasculature.

Q: The "Golden S" sign in bronchogenic carcinoma is characteristically seen in:

Bronchogenic carcinoma with upper lobe collapse. **Bronchogenic carcinoma with upper lobe collapse** - The "**Golden S sign**" is a classic radiographic finding that indicates an **endobronchial obstruction** in the presence of a collapsed upper lobe. - The inverted "S" shape is formed by the collapsed upper lobe (producing the convex lower portion) and the **mediastinal mass or hilar lesion** (producing the concave upper portion). *Bronchogenic carcinoma with lower lobe collapse* - Lower lobe collapse typically presents with different radiographic signs, such as the **silhouette sign** with the diaphragm or a generalized increase in density in the lower lung fields, not the Golden S sign. - The configuration of collapse in the lower lobe does not create the characteristic "S" curve. *Bronchogenic carcinoma in interlobular fissure* - A bronchogenic carcinoma located within an interlobular fissure would appear as a **mass lesion**, but it would not, by itself, produce the characteristic radiographic appearance of the Golden S sign, which requires an associated lobar collapse. - This location does not induce the **lobar atelectasis** necessary to form the specific "S" shape. *Hydatid cyst* - A **hydatid cyst** is a parasitic infection that typically presents as a well-defined, round or oval mass, sometimes with daughter cysts or a "water lily" sign if ruptured. - It is not associated with bronchial obstruction or lobar collapse in a manner that would create the characteristic "Golden S sign."

Q: The air crescent sign on a chest X-ray is indicative of which condition?

Invasive aspergillosis. ***Invasive aspergillosis*** - The **air crescent sign** on a chest X-ray is highly characteristic of **invasive aspergillosis**, especially in immunocompromised patients. - This sign represents a crescent of air separating a **necrotic lung focus** or **fungal ball** from the surrounding lung parenchyma. *Blastomycosis* - **Blastomycosis** is a fungal infection that typically manifests as pulmonary infiltrates, nodules, or masses, but rarely as an **air crescent sign**. - Its radiographic features are often non-specific and can mimic bacterial pneumonia or malignancy. *Pneumonia* - **Pneumonia** usually presents with **lobar or multifocal consolidation** or **interstitial infiltrates**, not typically with an air crescent sign. - The air crescent sign is generally associated with **necrotizing processes** or cavitary lesions, which are less common in typical bacterial pneumonia. *Bronchiectasis* - **Bronchiectasis** is characterized by **irreversible dilation of the bronchi**, leading to characteristic "tram track" or "ring" shadows on imaging. - It does not typically present with an **air crescent sign**, which is indicative of a specific cavitary or necrotic process within a mass.

Q: Which condition is associated with pseudobronchiectasis?

Atelectasis. ***Atelectasis*** - **Pseudobronchiectasis** refers to the apparent dilation of bronchi due to surrounding lung collapse, which is characteristic of **atelectasis** [1]. - As the collapsed lung tissue reduces in volume, the airways within that segment can appear relatively wider on imaging, mimicking true bronchiectasis [1]. *Lung abscess* - A **lung abscess** is a localized collection of pus within the lung parenchyma, often with a cavity. - While it can cause inflammatory changes, it does not typically lead to the radiographic appearance of dilated bronchi in the same way that surrounding lung collapse does. *Bronchopneumonia* - **Bronchopneumonia** is a patchy inflammation of the lung involving the bronchi and bronchioles and the adjacent alveoli. - It causes consolidation and inflammation, but not the *apparent* bronchial dilation seen in pseudobronchiectasis. *Emphysema* - **Emphysema** is characterized by permanent enlargement of the airspaces distal to the terminal bronchioles, with destruction of their walls. - This condition involves airspace destruction and airway collapse during expiration, not bronchial dilation caused by surrounding lung collapse.

Q: Apex of the lung is best assessed by

Lordotic view. ***Lordotic view*** - The **lordotic view** is a specialized chest X-ray projection specifically designed to visualize the **lung apices** clearly by projecting the clavicles superiorly. - This view is achieved by leaning the patient backward (lordotic position) while the X-ray beam is angled, or by angling the X-ray tube itself superiorly. *AP view* - The **AP (Anteroposterior) view** often projects the **clavicles over the lung apices**, obscuring them and making thorough assessment difficult. - This general chest X-ray view is primarily used when the patient cannot stand or sits upright for a PA view. *PA view* - Similar to the AP view, the standard **PA (Posteroanterior) view** can also have the **clavicles superimpose the lung apices**, making subtle apical pathology hard to detect. - While a routine chest X-ray, it's not optimal for detailed evaluation of the uppermost lung regions. *Oblique view* - **Oblique views** are primarily used to separate superimposed structures or to better visualize specific areas that are obscured in standard AP or PA views, but they are not the best for the apices. - They are often employed to assess the pleura, hilum, or specific lung segments by rotating the patient.

Q: Pleural plaques are best seen on which chest radiograph view?

Oblique view. ***Oblique view*** - An **oblique view** of the chest allows for better visualization of the **pleural surfaces** tangential to the X-ray beam, thereby highlighting calcified plaques more effectively than standard frontal views. - This projection helps to separate the pleura from overlying or underlying bony structures like the ribs, which can obscure pleural abnormalities in other views. *CXR PA view* - A standard **PA chest X-ray** may show pleural plaques, but their visibility can be limited by superimposition of ribs and other chest wall structures. - Small or non-calcified plaques might be missed on a PA view due to the inherent two-dimensional nature of the image. *CXR Lordotic view* - A **lordotic view** is primarily used to evaluate the **lung apices** and the middle lobe or lingula, particularly for suspected lesions like tuberculosis or apical fibrosis. - It is not optimized for visualizing pleural surfaces along the chest wall, where most pleural plaques occur. *CXR AP view* - An **AP chest X-ray** is typically performed when a patient cannot stand or sits upright, often in a hospital setting. - Similar to the PA view, it suffers from superimposition issues and often yields a lower quality image due to magnification and cardiac silhouette enlargement, making detailed pleural assessment challenging.

Q: Inverted mustache sign is seen in

Pulmonary Venous hypertension. ***Pulmonary Venous hypertension*** - The "inverted mustache sign" refers to the **engorgement of pulmonary veins** visible on a chest X-ray, typically seen in severe pulmonary venous hypertension. - This sign indicates increased pressure within the pulmonary venous system, often due to **left heart failure** or **mitral valve disease**. *HOCM* - **Hypertrophic obstructive cardiomyopathy** (HOCM) is characterized by thickening of the ventricular septum, leading to outflow tract obstruction. - While it can lead to elevated left atrial pressures and pulmonary venous congestion, the "inverted mustache sign" is **not a specific or classic radiographic finding** for HOCM. *Amyloidosis* - **Cardiac amyloidosis** leads to restrictive cardiomyopathy due to **amyloid protein deposition** in the myocardial tissue. - This can cause **diastolic dysfunction** and elevated pulmonary venous pressures, but the specific "inverted mustache sign" is not directly associated with amyloidosis as a primary or pathognomonic finding. *Small VSD* - A **small ventricular septal defect** (VSD) typically results in a **left-to-right shunt**, which may cause increased pulmonary blood flow, but usually not significant enough to cause severe pulmonary venous hypertension or the "inverted mustache sign." - Significant pulmonary venous hypertension and engorgement are more characteristic of conditions affecting the **left side of the heart** (e.g., mitral stenosis, left ventricular failure).

Question 1

On chest radiology, "egg-shell calcification" is seen in:

Accepted Answer

Silicosis

Answer

Asbestosis

Answer

Coal-worker pneumoconiosis

Answer

Berylliosis

Question 2

You are shown PA and lateral chest radiographs from a 53-year-old woman with mild dyspnea. Which one of the following is the most likely diagnosis based on the imaging?

Accepted Answer

Solitary fibrous tumor of the pleura

Answer

Parapneumonic effusion

Answer

Lung cancer

Answer

Malignant pleural mesothelioma

Question 3

Investigation of choice in bronchiectasis?

Accepted Answer

HRCT

Answer

Bronchoscopy

Answer

Chest X-ray

Answer

MRI

Question 4

Miliary shadow in a chest X-ray is typically seen in all of the following conditions except:

Accepted Answer

Klebsiella

Answer

TB

Answer

Metastasis

Answer

Sarcoidosis

Question 5

The "Golden S" sign in bronchogenic carcinoma is characteristically seen in:

Accepted Answer

Bronchogenic carcinoma with upper lobe collapse

Answer

Bronchogenic carcinoma with lower lobe collapse

Answer

Bronchogenic carcinoma in interlobular fissure

Answer

Hydatid cyst

Question 6

The air crescent sign on a chest X-ray is indicative of which condition?

Accepted Answer

Invasive aspergillosis

Answer

Blastomycosis

Answer

Pneumonia

Answer

Bronchiectasis

Question 7

Which condition is associated with pseudobronchiectasis?

Accepted Answer

Atelectasis

Answer

Lung abscess

Answer

Emphysema

Answer

Bronchopneumonia

Question 8

Apex of the lung is best assessed by

Accepted Answer

Lordotic view

Answer

AP view

Answer

PA view

Answer

Oblique view

Question 9

Pleural plaques are best seen on which chest radiograph view?

Accepted Answer

Oblique view

Answer

CXR PA view

Answer

CXR Lordotic view

Answer

CXR AP view

Question 10

Inverted mustache sign is seen in

Accepted Answer

Pulmonary Venous hypertension

Answer

HOCM

Answer

Amyloidosis

Answer

Small VSD

Chest Radiology — MCQs

Chest Radiology — MCQs

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