I II III The Chest X-Ray Differential Diagnosis in Conventional Radiology Francis A. Burgener, M.D. Martti Kormano, M.D. Tomi Pudas, M.D. Professor of Radiology Formerly Professor and Chairman Department of Radiology University of Rochester Department of Radiology University of Turku Medical Center University of Turku Turku, Finland Rochester, N.Y., U.S.A. Turku, Finland 2nd revised edition 498 illustrations Thieme Stuttgart · New York IV LibraryofCongressCataloging-in-PublicationData Important Note: Medicine is an ever-changing science un- isavailablefromthepublisher. dergoing continual development. Research and clinical ex- perience are continually expanding our knowledge, in par- ticularourknowledgeofpropertreatmentanddrugtherapy. Insofar as this book mentions any dosage or application, readersmayrestassuredthattheauthors,editorsandpub- lishershavemadeeveryefforttoensurethatsuchreferences areinaccordancewiththestateofknowledgeatthetimeof productionofthebook. Nevertheless this does not involve, imply, or express any guaranteeorresponsibilityonthepartofthepublishersin respectofanydosageinstructionsandformsofapplication statedinthebook.Everyuserisrequestedtoexaminecare- fully the manufacturers’ leaflets accompanying each drug andtocheck,ifnecessaryinconsultationwithaphysicianor specialist,whetherthedosageschedulesmentionedtherein orthecontraindicationsstatedbythemanufacturersdiffer fromthestatementsmadeinthepresentbook.Suchexami- nation is particularly important with drugs that are either rarely used or have been newly released on the market. Everydosagescheduleoreveryformofapplicationusedis entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishersanydiscrepanciesorinaccuraciesnoticed. ©2006GeorgThiemeVerlag, Someoftheproductnames,patentsandregistereddesigns Rüdigerstraße14,D-70469Stuttgart,Germany referredtointhisbookareinfactregisteredtrademarksor http://www.thieme.de proprietarynameseventhoughspecificreferencetothisfact isnotalwaysmadeinthetext.Therefore,theappearanceofa ThiemeNewYork,333SeventhAvenue, name without designation as proprietary is not to be con- NewYork,N.Y.10001,U.S.A struedasarepresentationbythepublisherthatitisinthe http://www.thieme.de publicdomain. Thisbook,includingallpartsthereof,islegallyprotectedby Coverdesign:MartinaBerge,Erbach copyright. Any use, exploitation or commercialization out- TypesettingbyprimustypeHurlerGmbH, sidethenarrowlimitssetbycopyrightlegislation,without D-73274Notzingen the publisher’s consent, is illegal and liable to prosecution. PrintedinGermanybyGrammlich,Pliezhausen Thisappliesinparticulartophotostatreproduction,copying, mimeographingorduplicationofanykind,translating,prep- ISBN3-13-107612-7(GTV,Stuttgart) aration of microfilms, and electronic data processing and ISBN1-58890-446-6(TMP,NewYork) 12345 storage. V Preface Conventionalradiographyremainsthebackboneinthoracic wasupdated,manyillustrationsreplacedandlargenumbers radiology despite the advent of newer and more exciting ofnewillustrationsadded. imaging techniques such as computed tomography, high A changing of the guard has also taken place. Since Dr. resolution computed tomography, magnetic resonance im- Martti Kormano’s professional endeavors do no longer in- aging and most recently positron emission tomography. In cludeclinicalradiology,hefeltnolongeruptothetasktoup- contrast to many of these newer methods, conventional datehisoriginalcontributionstothetext.Hewashowever radiographyispracticednotonlybyradiologistsbutalsoby very fortunate to find in Dr. Tomi Pudas a very talented a large number clinicians and surgeons. With each exami- young radiologist to take over the revision of the chapters nation, one is confronted with radiologic findings that re- originallypreparedbyhim. quireinterpretationinordertoarriveatageneraldiagnos- Ihopethisneweditionwillbeaswellreceivedasitspre- tic impression and a reasonable differential diagnosis. To decessors in the past that produced several spin-off books assist the film reader in attaining this goal this book is andweretranslatedintofiveforeignlanguages.Theconcept based upon radiographic finding unlike most other text- ofanimagingpatternapproachintabularformratherthana books in radiology that are disease oriented. Since many diseaseorientedtextwasintroducedin1985withtheorigi- diseases present radiographically in a varicty of manifesta- nal edition and has since been adopted by many authors. I tions some overlap in the text is unavoidable. To minimize feel complimented by the old cliché, “imitation is the repetition the differential diagnosis of a radiographic find- sincerestformofflattery.“ ings is presented in tabular form whenever feasible. Most Thisbookismeantforphysicianswithsomeexperiencein tablesdonotonlylistthevariousdiseasesthatmaypresent chestradiologywhowishtostrengthentheirdiagnosticacu- radiologicallyinaspecificpattern,butalsodescribeinsuc- men.Itisacomprehensiveoutlineofradiographicfindings cinct form other characteristically associated radiographic and it should be particularity useful to radiology residents findings and pertinent clinical data. Radiographic illustra- preparingfortheirspecialistexaminations,especiallysince tionsanddrawingsareincludedtodemonstratevisuallythe theexposuretoconventionalradiographyduringtheirtrain- radiographic features under discussion. ingcontinuouslydecreasedinthepastinfavorofnewerim- The transition from film to digital radiography had the aging modalities. Any physician involved in the interpreta- greatestimpactonconventionalradiologysincethepublica- tion of conventional chest radiograph examinations should tionofthelastedition.Thischangehoweverdidnotaffect findthisbookhelpfulindirectproportiontohiscuriosity. thewayradiologicdiagnosesareascertained.Sincethepub- Itismyhopethatthisneweditionwillbeaswellreceived lication of the last edition in 1992 the name of a few dis- asthepreviousonesbymedicalstudents,residents,radiolo- ordershaschanged(e.g.,histiocytosisXtoLangerhanscell gists and physicians involved in the interpretation of con- histiocytosis) and a few disease are newly recognized (e.g. ventionalchestradiographswere. severeacuterespiratorydistresssyndromeorSARS).These facts were taken into account in the new edition. The text FrancisA.Burgener,M.D. VI Acknowledgements Itisimpossibletothankindividuallyallthosewhohelpedto I wish to express also many thanks to Jeanette Griebel, preparethethirdeditionofthistextbook.Iwishtoacknowl- IonaMackey,andMarcellaMaierfortheirassistanceinpre- edgethestaffofThieme,inparticularDr.CliffordBergman paringthereferencesandtoShirleyCappielloforhergeneral andMr.GertA.Krüger. assistance. Last, but not least, I am most grateful to Alyce IamdeeplyindebtedtoDr.GertrudGollman,Steinacham NorderwholefttheUniversityandmeafter30yearsforthe Attersee,Austria,whotranslatedthelasteditionofthistext richness of the industry. She is the only person capable of into German and suggested many alterations and correc- deciphering my longhand and, as in the past, did a superb tions,whichhavebeenincorporatedintothisnewedition. job in typing, editing, and proofreading the manuscript of My gratitude goes to all the radiologists whose coopera- theneweditionofthistext.Despiteherheavyworkloadas tion made available illustrative cases to compliment the executive assistant in her new endeavor. Alyce was kind originalcollectionortoreplaceolderillustrations.Iamin- enoughtoperformthistaskinhersparetime,forwhichIam debtedtoDrs.StevenP.Meyers,JohnnyU.V.Monu,andGwy greatlyappreciative. Suk Seo, all staff members of the University of Rochester FinallyIappreciatethesupportofmywifeTherese,who RadiologyDepartment,andtotheformerresidentsDrs.John has generously given her precious family time for the pre- M. Fitzgerald and Wael E. A. Saad for providing selected parationofthisbook. cases. FrancisA.Burgener,M.D. I would like to express my deepest gratitude to honorary radiology.ThemanyfascinatingdiscussionsIhavehadwith professor Martti Kormano who invited me to carry on his Drs. Seppo Kortelainen and Teemu Paavilainen brought me workinthisnewedition.Icontinuetoadmirethemassive muchdelight,onnon-radiologicaltopicsasmuchasonpro- workthatheandDr.Burgeneroriginallyputintotheproject fessionalsubjects. intheearlynineteen-eighties.Thehundredsofhourswhich Ialsoexpresssincerethankstothestaffofthepublishers, Dr. Kormano and I have spent together editing this edition Thieme, especially to Dr. Clifford Bergman and Mr. Gert havebeenagreatpleasure.Itwasafascinatingtimeinmy Krüger. Finally, much gratitude is due to Mr. Markku life. Livanaien for his valuable assistance with technical ques- IespeciallywanttothankDrs.KimmoMattilaandSeppo tions,andtoMs.PirjoHelankoforallherhelpwithgeneral Koskinen for introducing me to musculoskeletal radiology, matters.Manyotherindividualshelpedinvariouswayswith and for their extraordinary teaching and support. Many thisproject,andthoughIcannotnamethemall,Iamgrateful thanks also belong to Drs. Erkki Svedström, Risto Elo, and fortheircontributions. PeterB.Deanforencouragingmeonmywayinthefieldof TomiPudas,M.D. VII Contents 1 Cardiac Enlargement ................... 3 7 Pulmonary Edema and Symmetrical MarttiKormanoandTomiPudas Bilateral Infiltrates ..................... 143 FrancisA.Burgener 2 Mediastinal or Hilar Enlargement ......... 43 MarttiKormanoandTomiPudas 8 Pulmonary Nodules and Mass Lesions ..... 157 FrancisA.Burgener 3 Pleura and Diaphragm ................. 71 MarttiKormanoandTomiPudas 9 Pulmonary Cavitary and Cystic Lesions .... 175 FrancisA.Burgener 4 Intrathoracic Calcifications .............. 83 MarttiKormanoandTomiPudas 10 Hyperlucent Lung ..................... 189 MarttiKormanoandTomiPudas 5 Alveolar Infiltrates and Atelectasis ........ 95 FrancisA.Burgener References ............................... 202 6 Interstitial Lung Disease ................ 119 Index ................................... 203 FrancisA.Burgener VIII Abbreviations ACTH adrenocorticotropichormone LIP lymphoidinterstitialpneumonitis AIDS acquiredimmunedeficiencysyndrome LL lowerlobes LLL leftlowerlobe ALL acutelymphoblasticleukemia LLQ leftlowerquadrant AML acutemyeloblasticleukemia LUL leftupperlobe ANCA antineutrophilcytoplasmoticautoantibodies LUQ leftupperquadrant ANT anterior LV leftventricle AP anteroposterior M male APVR anomalouspulmonaryvenousreturn MAI Mycobacteriumaviumintracellulare ARDS acuterespiratorydistresssyndrome MFH malignantfibroushistiocytoma ATN acutetubularnecrosis ML middlelobe AV arteriovenous MPS mucopolysaccharidosis AVF arteriovenousfistula MR magneticresonance AVM arteriovenousmalformation MRI magneticresonanceimaging AVN avascularnecrosis NHL non-Hodgkinlymphoma Bx biopsy NUC nuclearmedicine CAD coronaryarterydisease PA posteroanterior CAM cysticadenomatoidmalformation PAPVR partialanomalouspulmonaryvenousreturn CHF congestiveheartfailure PATH pathology CID cytomegalicinclusiondisease PAVM pulmonaryarteriovenousmalformation CLL chroniclymphaticleukemia PCP Pneumocystiscariniipneumonia CMV cytomegalovirus PDA patentductusarteriosus CNS centralnervoussystem PE pulmonaryembolism COPD chronicobstructivepulmonarydisease PET positronemissiontomography CT computedtomography PNET primitiveneuroectodermaltumor DD differentialdiagnosis PO peroral DIC disseminationintravascularcoagulation RA rheumatoidarthritis DIP desquamativeinterstitialpneumonitis RA rightatrium EG eosinophilicgranuloma RBC redbloodcell F female RDS respiratorydistresssyndrome GE gastroesophageal RES reticuloendothelialsystem GIP giantcellinterstitialpneumonitis RLL rightlowerlobe Hb hemoglobin RLQ rightlowerquadrant HD Hodgkindisease RML rightmiddlelobe HIV humanimmunodeficiencyvirus RUL rightupperlobe HRCT high-resolutionCT RV rightventricle Hx history SARS severeacuterespiratorydistresssyndrome IM intramuscular SLE systemiclupuserythematosus IVC inferiorvenacava TAPVR totalanomalouspulmonaryvenousreturn L left TB tuberculosis LA leftatrium TNM tumor-node-metastasis LCH Langerhanscellhistiocytosis UIP usualinterstitialpneumonitis LE lupuserythematosus US ultrasound 1