Chapter A12: Atlas of Chest Imaging

Normal chest x-ray. Normal posterior-anterior (A) and lateral (B) radiographs of the chest.

Normal CT. Normal axial CT images of the chest at the levels of the aortic arch (A), pulmonary artery bifurcation (B), and pulmonary vein (C).

Paraseptal emphysema. Axial CT image of the chest demonstrating severe paraseptal emphysema.

Centrilobular emphysema. Axial CT image of the chest of a patient with centrilobular emphysema. The red arrow indicates an area of moderately severe disease in the lingula. Note that the pulmonary artery within the secondary pulmonary lobule is still visible and surrounded by areas of hypoattenuation (emphysema). The yellow arrow indicates an area of more advanced centrilobular emphysema where the areas of hypoattenuation are more confluent and the centilobular pulmonary artery is less apparent but still visible.

Panlobular emphysema. Axial CT image of the chest demonstrating severe panlobular emphysema in a patient with α₁ antitrypsin deficiency.

Bullous emphysema. Coronary CT reconstruction of the chest of a patient with a large bulla at the left apex (red arrow). Note also the presence a suture line in the left upper lobe at the location of prior bullectomy (yellow arrow).

Interstitial lung abnormalities. Axial CT images of the chest of a patient with interstitial lung abnormalities at baseline (A) and 5 years later (B). Note the evidence of mild progression evidenced by an increase in ground glass (yellow arrow) and worsening brochiolectasis (red arrow). Interstitial lung abnormalities share clinical and genetic associations with idiopathic pulmonary fibrosis (IPF), and in some cases, they may represent early or mild IPF.

Idiopathic fibrosis. Axial CT image (A) and coronal reconstruction (B) of the chest of a patient with severe idiopathic fibrosis. Note the presence of both honeycombing and traction bronchiectasis as well as the severe volume loss.

Hypersensitivity pneumonitis. Axial CT image of the chest demonstrating reticular changes and peribronchovascular ground glass as well as early traction bronchiectasis consistent with hypersensitivity pneumonitis in a patient ultimately found to have "bird fancier's lung."

Nonspecific interstitial pneumonitis. A. Axial CT image of the chest demonstrating peripheral ground-glass opacities with immediate subpleural sparing in a patient with cellular nonspecific interstitial pneumonitis (NSIP). B. Also shown is an axial CT image of the chest from a separate patient with fibrotic NSIP, which is typified by reticular opacities including subpleural reticulation and thickening of the bronchovascular bundles as well as, in this case, traction bronchiectasis.

Combined pulmonary fibrosis and emphysema. Coronal CT reconstruction of the chest demonstrating honeycombing and traction bronchiectasis consistent with usual interstitial pneumonia at the bases (yellow bracket) consistent with idiopathic pulmonary fibrosis at the lung base and severe paraseptal emphysema apically (red bracket). The presence of both of these entities in the same patient is sometimes referred to as combined pulmonary fibrosis and emphysema (CPFE). Whether this represents a unique disease entity or the coexistence of two separate diseases within a single patient remains unclear, but patients with both findings do appear to have high mortality, often related to pulmonary hypertension and right heart failure, as was the case for this patient.

Chronic obstructive pulmonary disease (COPD)/bronchiectasis. Axial CT images of the chest of a patient with COPD who does not initially have evidence of bronchiectasis (yellow arrow, A), but who develops it over the course of 5 years of follow-up (red arrow, B). This is evidenced radiographically by the fact that at baseline the patient's airways are the same size or smaller than the adjacent pulmonary artery (yellow arrow, A) but, at follow-up, the airways are larger than the adjacent pulmonary artery (red arrow, B).

Cystic fibrosis and bronchiectasis. Axial CT images of the chest of a patient with cystic fibrosis. Note the presence of bronchial wall thickening and cylindrical bronchiectasis on the baseline image (yellow arrow, A) which progressed to more severe varicose and cystic bronchiectasis (red arrow, B) over 5 years of follow-up. This patient has recurrent, dense, right-sided pneumonia and atelectasis as well.

Pulmonary embolism. Axial CT images demonstrating large pulmonary embolus (A) with associated right ventricular dilation and intraventricular septal flattening (B). After catheter-directed thrombolysis, there is evidence of recanalization (C) as well as dramatic improvement in the right ventricular dilation and interventricular septal flattening (D).

Coronary artery calcifications. Axial CT image and coronal reconstruction of the chest in a patient with severe coronary artery calcifications including of the left anterior descending artery (yellow arrow, A) and the right coronary artery (red arrow, B).

Nodules. Axial CT images of the chest demonstrating a ground glass nodule (yellow arrow, A), a mixed attenuation nodule (red arrow, B), and a solid nodule (blue arrow, C). Notably, all three patients' nodules were identified in the setting of a lung cancer screening program. All nodules underwent biopsy, and all were found to have lung adenocarcinoma.

Pneumatocele. Axial CT image of the chest demonstrating a solitary thin-walled cyst consistent with pneumatocele.

Lymphangioleiomyomatosis. Axial CT image of the chest demonstrating severe cystic disease in a patient with lymphangioleiomyomatosis.

Eosinophilic granuloma. Axial CT images of the chest from two patients with eosinophilic granuloma of the lung, which is also referred to as pulmonary histiocytosis X or pulmonary Langerhans cell histiocytosis. The patient on the left (A) has micronodule-predominant disease, often seen earlier in the disease course, whereas the patient on the right (B) has cystic disease, often seen later in the disease course.

Azygous lobe. Axial CT image of the chest demonstrating the presence of an azygous lobe, a normal variant.

Bronchopulmonary dysplasia. Axial CT image of the chest demonstrating severe bronchopulmonary dysplasia in a patient with history of extreme prematurity.

Radiation-related fibrosis. Axial CT image of the chest demonstrating severe radiation-related fibrosis and calcification of mediastinal structures as the result of high-dose radiation for non-small-cell lung cancer. A similar pattern is often seen in older patients who received mantle radiation for Hodgkin lymphoma at a young age.

Drowning. Anterior-posterior chest radiograph demonstrating bilateral alveolar infiltrates consistent with severe acute respiratory distress syndrome in the setting of fresh-water drowning.

Pulmonary alveolar proteinosis. Axial CT image demonstrating ground-glass opacities and interlobular septal thickening, so-called "crazy paving," in a patient with pulmonary alveolar proteinosis.

Interstitial lung disease with pneumomediastinum left-sided pneumothorax and subcutaneous emphysema. Axial CT image of the chest of a patient with interstitial lung disease who has developed pneumomediastinum (yellow arrow), a left-sided pneumothorax (red arrow), and significant subcutaneous emphysema (blue arrow).

Pleural plaques. Axial CT image of a patient with diffuse, nodular pleural plaques in the setting of prior asbestos exposure.

Pleural effusion. Posterior-anterior chest radiograph demonstrating a left-sided pleural effusion in the setting of mesothelioma.

Anteroposterior (AP) chest radiograph of large left pleural effusion. AP chest radiographs demonstrating a large left pleural effusion before (A) and after (B) drainage. Note that the image on the right (B) demonstrates lung markings in the left hemithorax and a new small-bore chest tube, findings consistent with drainage of the pleural effusion and reexpansion pulmonary edema.

Type III diaphragmatic hernia. Coronal CT reconstruction of the chest demonstrating a hiatal hernia. In this case, both the gastroesophageal junction and gastric fundus have herniated through the hiatus. This is referred to as a type III diaphragmatic hernia.

Type IV diaphragmatic hernia. Coronal CT reconstruction of the chest demonstrating a hiatal hernia. In this case, both the stomach and colon have herniated through the diaphragm. This is referred to as a type IV diaphragmatic hernia.

Hilar lymph node calcification. Axial CT image of the chest demonstrating hilar lymph node calcification consistent with prior Histoplasma infection.

Diffuse tuberculosis. Anterior-posterior chest radiograph image demonstrating upper lobe–predominant, diffuse, hazy opacities due to reactivated Mycobacterium tuberculosis in the setting of anti–tumor necrosis factor use.

COVID-19. Anterior-posterior chest radiographs of a patient prior to the development of COVID-19–related respiratory failure (A), early in the development of COVID-19–related respiratory failure/acute respiratory distress syndrome (B), and with severe acute respiratory distress syndrome and respiratory failure (C) in the setting of COVID-19 infection.