Chest Radiology Practice Questions

Q: Which of the following conditions is most commonly associated with miliary mottling in the lungs?

Pulmonary tuberculosis. ***Pulmonary tuberculosis*** - **Miliary mottling** on chest X-ray is a classic radiographic feature of **miliary tuberculosis**, which results from hematogenous dissemination of *Mycobacterium tuberculosis* to the lungs. - The term "miliary" refers to the resemblance to **millet seeds**, with characteristic **1-3mm uniformly distributed micronodules** scattered diffusely throughout both lung fields. - These small, diffuse nodules represent widespread tiny **granulomas** formed in response to the disseminated bacilli. - **Miliary TB is the prototype condition** for true miliary mottling pattern. *Sarcoidosis* - While sarcoidosis can cause lung nodules, they are typically larger and more concentrated in the **perihilar regions** and upper lobes, often presenting as **lymphadenopathy** and discrete nodules rather than diffuse miliary patterns. - The nodules in sarcoidosis are **non-caseating granulomas**, but their distribution and size usually differentiate them from miliary tuberculosis. *Histiocytosis X* - **Pulmonary Langerhans cell histiocytosis (Histiocytosis X)** typically presents with a combination of **cysts and nodules**, predominantly in the upper and middle lung zones. - The radiological appearance is often described as **stellate nodules** and multifocal cysts, which is distinct from the fine, diffuse pattern of miliary mottling. *Pulmonary metastasis* - **Pulmonary metastases** usually appear as discrete, well-defined nodules or masses of varying sizes, often referred to as "**cannonball lesions**" if large, and are typically scattered unevenly throughout the lungs. - The metastatic lesions are generally larger and fewer in number compared to the fine, widespread micronodules seen in miliary mottling.

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: Which of the following chest X-ray findings is least likely to be associated with tuberculosis in patients with HIV?

Lupus vulgaris. ***Lupus vulgaris*** * **Lupus vulgaris** is a form of **cutaneous tuberculosis** that affects the skin and is not a chest X-ray finding. * It is a localized skin lesion, typically on the face or neck, and does not manifest with pulmonary radiographic changes. *Miliary pattern* * **Miliary pattern** on chest X-ray appears as diffuse **small nodular infiltrates** (1-3 mm) distributed throughout both lung fields, representing hematogenous dissemination of *Mycobacterium tuberculosis*. * This finding is common in HIV patients with **disseminated (miliary) tuberculosis** and reflects severely impaired cell-mediated immunity. * The term "miliary" refers to the millet seed-like appearance of the nodules. *Pleural effusion* * **Pleural effusion** is a common manifestation of tuberculosis, especially in immunocompromised individuals like those with HIV, often appearing as blunting of the **costophrenic angles** on chest X-ray. * It is caused by an inflammatory reaction to mycobacterial antigens in the pleural space. *Hilar lymphadenopathy* * **Hilar lymphadenopathy** is a common chest X-ray finding in both primary and reactivated tuberculosis, particularly in HIV-infected patients due to an altered immune response. * Enlarged lymph nodes near the **hilum** are often prominently visible and can be a sole chest X-ray finding in early or atypical presentations.

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: Double density sign in mitral stenosis is a sign of enlargement of which structure?

Left Atrium. ***Left Atrium*** - The **double density sign**, or "double contour" sign, on a chest X-ray in mitral stenosis indicates an enlarged **left atrium**. - This occurs because the enlarged left atrium causes its right border to project through the right atrial silhouette, creating a **second, denser shadow**. *Right Atrium* - Enlargement of the right atrium typically presents as an increased prominence of the **right heart border** and is not associated with the double density sign. - Right atrial enlargement is more commonly seen in conditions like **tricuspid stenosis** or **pulmonary hypertension**. *Left Auricle* - The left auricle (or left atrial appendage) projects anteriorly and to the left, and its enlargement would typically manifest as a **bulge along the left heart border**, particularly between the pulmonary artery and the left ventricle. - While it is a part of the left atrium, the specific "double density" sign refers to the *main body* of the left atrium projecting posteriorly and to the right. *Right Auricle* - The right auricle is a small, muscular appendage of the right atrium that is not directly visualized as a separate contour on a standard chest X-ray in a way that would produce a "double density" sign. - Its enlargement would contribute to overall **right atrial enlargement**, which has different radiographic features.

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: The 1-2-3 sign on chest X-ray is characteristically associated with which of the following conditions?

Coarctation of aorta. ***Coarctation of aorta*** - The **'1-2-3 sign'** (also known as the **'E sign'** or **'reverse 3 sign'**) on a chest X-ray is characteristic of coarctation of the aorta. - This sign is formed by three contours along the left mediastinal border: a dilated **proximal aorta/left subclavian artery (1)**, an **indentation at the coarctation site (2)**, and **post-stenotic dilation of the descending aorta (3)**. - This creates a figure resembling the number "3" or a reverse "E" on the frontal chest radiograph. *Tetralogy of Fallot* - Characteristically presents with a **"boot-shaped heart"** (cœur en sabot) on chest X-ray due to right ventricular hypertrophy and pulmonary artery hypoplasia. - Does not typically show the specific '1-2-3 sign' related to aortic indentation. *Mitral stenosis* - Chest X-ray findings often include **left atrial enlargement**, **pulmonary vascular congestion**, and sometimes straightening of the left heart border. - The '1-2-3 sign' is not associated with mitral valve disease. *Aortic stenosis* - Chronic aortic stenosis can lead to **left ventricular hypertrophy** and post-stenotic dilatation of the ascending aorta, but not the specific '1-2-3 sign'. - While there might be changes in the aortic contour, it typically doesn't exhibit the characteristic notches seen in coarctation.

Question 1

Which of the following conditions is most commonly associated with miliary mottling in the lungs?

Accepted Answer

Pulmonary tuberculosis

Answer

Sarcoidosis

Answer

Histiocytosis X

Answer

Pulmonary metastasis

Question 2

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

Accepted Answer

Silicosis

Answer

Asbestosis

Answer

Coal-worker pneumoconiosis

Answer

Berylliosis

Question 3

Which of the following chest X-ray findings is least likely to be associated with tuberculosis in patients with HIV?

Accepted Answer

Lupus vulgaris

Answer

Pleural effusion

Answer

Hilar lymphadenopathy

Answer

Miliary pattern

Question 4

Investigation of choice in bronchiectasis?

Accepted Answer

HRCT

Answer

Bronchoscopy

Answer

Chest X-ray

Answer

MRI

Question 5

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 6

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 7

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 8

Double density sign in mitral stenosis is a sign of enlargement of which structure?

Accepted Answer

Left Atrium

Answer

Right Atrium

Answer

Left Auricle

Answer

Right Auricle

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

The 1-2-3 sign on chest X-ray is characteristically associated with which of the following conditions?

Accepted Answer

Coarctation of aorta

Answer

Mitral stenosis

Answer

Tetralogy of Fallot

Answer

Aortic stenosis

Chest Radiology — MCQs

Chest Radiology — MCQs

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