Pediatric Radiology

 COMMENT ON NORMAL CHEST: Plain X-Rays chest post-anterior view . The patient is centralized. Normal bony structures. Central mediastinum. Normal cardio-thoracic ratio & cardiac position . Both lung fields are clear with normal hilar shadow. Both costopherenic recesses are clear with normal cardio-pherenic angle.

NORMAL

Remember in each case:

1. Obtaining Clinical history. 2. Proper technique. i.e. Good exposure 3. Patient position i.e. centralized or not?. 4. Orientation of the film , i.e. left or right marked. 5. Recognition of film artifacts. 6. Systematic approach.

Comment:
Plain X-rays chest P.A. view. Normal bony cage. Central mediastinum. Bilateral hyperinflation of both lungs. Non-homogenous opacity occupying the middle lobe of the right lung. Diagnosis: mostly Rt. Middle lobe pneumonia.

Right upper lobe pneumonia

Comment:
Plain X-rays chest P.A. view. Traction of mediastinum towards the Rt. Side, with narrowing of ipsilateral ribs indicating volume loss. Non homogenous opacification filling the Rt. Upper hemithorax. Compensatory hyperinflation of Lt. lung. D/ mostly Rt. Upper lobe pneumonia.

Trachea

Right upper lobe pneumonia

Comment:
Left basal opacification rising towards the axilla. Oblitration of the Lt. costophrenic recess. Compensatory hyperinflation of Rt. Lung. Dignosis:  Left sided pleural effusion, underlying parenchymal lesion could not be excluded. ? SYNPNEUMONIC EMPYEMA

Right upper lobe pneumonia

Comment:
Massive homogenous opacification of the left hemithorax with obliteration of the Lt. costo-phrenonic angle. Shifted mediastinum towards the contrlateral (Rt.) side. Underlying pathology of Lt. lung could not be excluded. D/ Left-sided massive pleural effusion.

 Homogenous opacification oblitrarating the left costophrenic angle. Air-fluid level on the left side. Dignosis:  Left-sided Hydropneumothorax

Rt. Lower lobe pneumonia. Preserved Rt. Costophrenic recess. It is NOT a case of pleural effusion.

Bilateral miliary shadows (highly suggestive of MILIARY T.B.)

COMMENT:
These PA and lateral chest radiograph views are taken in a 7-month old with miliary TB. There are multiple small nodules throughout the lungs bilaterally. There is a focal consolidation in the right upper lobe.

Substantial clearing of the multiple small nodular densities and clearing of the right upper lobe consolidation after anti-tuberculous therapy

Comment:
Diffuse air occupying the left hemithorax (Jet black , devoid of lung markings). Underlying collapse of the Left lung. Mediastinal shift towards Rt. Side. A case of:  Left-sided tension pneumothorax.

Air-fluid level

Massive pleural effusion with hydropneumothorax on the Lt. side.

Herniation of the bowel into the left hemithorax with contralteral mediastinal shift. Dignosis: Congenital diaphragmatic hernia.

Congenital diaphragmatic hernia.

Congenital diaphragmatic hernia.

Red arrow points to end of nasogastric tube blocked from entering the distal esophagus.  Note the gasless abdomen

(ESOPHAGEAL ATRESIA)

Ground glaas appearance. Diminished lung volume Air bronchogram.

(HYALINE MEMBRANE DISEASE).. Versus congenital pneumonia..

COLLAPSED LUNG

PNEUMOTHORAX

HYALINE MEMBRANE DISEASE

Right upper lobe large thin-walled pneumatocele

Comment:
Massive hyperinflation of the left lung with mediastinal herniation. Significant mediastinal shift with collapse of the contralateral right lung.

 CONGENITAL LOBAR EMPHYSEMA.

Chest radiograph showing left lower lobe consolidation with large cavitary lesion. (Lung abscess)

Rt. upper and middle lobe massive pneumonia

Comment:
Jet black air with underlying lung collapse of the Rt. Lung. Evident line of demarcation between air and the collapsed lung. No significant mediastinal shift.

 Rt-sided pneumothorax.

PNEUMOMEDIATINUM (A cushion of air delineating the heart)

Lt. sided pneumothorax

Rt. middle lobe pneumonia

Air-fluid level- HYDROPNEUMOTHORAX on Rt. side.

Comment:
Bilateral nodular opacities with fluffy cotton appearance infiltrating both lung fields. Ring shadow with well-delineated wall occupying the right upper lobe. (lung abscess). This picture is highly suggestive of extensive bronchopneumonia mostly in an immuno-compromised subject.

Wavy sail appearance of normal thymus on right.

Left-sided Massive pleural effusion

Rt. upper lobe pneumonia Highly suggestive of aspiration pneumonia.

Bronchial asthma

Comment:
Bilateral hyperinflation of both lungs ( jet black lung fields) with increased volume . Flattened copulae of diaphragm . widened intercostal spaces . Vertical cardiac shadow . Features are highly suggestive of air trapping : 1.Bronchial asthma (acute attack) 2.Emphysema (older patients)

Bilateral hyperinflation (asthma) with Rt upper lobar consolidation

Comment:
Patchy or fluffy infiltrates of ill-defined margins distributed throughout both lung fields. Picture of bilateral extensive bronchopneumonia  ? Staphylococcal  ? Fungal  ? pneumocystis carinii

Lung abscess in the right middle lobe

Rt. Pleural effusion with shifted mediastinum

Bilateral basal Bronchiactatic changes

Lung abscess in the Lt. upper lobe

Left-sided Plural effusion

Confluent bronchopneumonic changes on the Rt. side

Bilateral extensive bronchopneumonic changes for differential diagnosis

Right-sided Pleural effusion

Rt. upper lobe pneumonia

Left-sided massive pleural effusion

SKELETAL SYSTEM

 Plain X-ray wrist joint showing: Decreased bone density. Broadening, cupping and fraying of distal ends of radius and ulna. Wide distance between distal ends of radius and ulna & carpal & metacarpal bones.

 DIAGNOSIS: ACTIVE RICKETS

ACTIVE RICKETS

ACTIVE RICKETS

ACTIVE RICKETS

AN OSTEOLYTIC LESION OF THE SKULL. D.D. HISTIOCYTOSIS VERSUS METASTASIS

Protruded maxilla, and characteristic SUN-RAYS appearance. D/ chronic hemolytic anemia mostly beta-thalassemia major

MULTIPLE OSTEOLYTIC LESIONS

HAIR STANDING ON AN END OR SUN-RAYS APPEARANCE

RACHITIC ROSARIES

Bat-man appearance of skull and separation of the sutures (OSTEOPETROSIS)

LATERAL Plain film of skull showing generalized increased density and thickening of the skull base and calvarium. (OSTEOPETROSIS)

Chest film shows generalized increased density of the bones and squaring off of the anterior rib margins. (OSTEOPETROSIS)

X-RAY ABDOMEN STANSDING

MULTIPLE AIR-FLUID LEVELS. MOSTLY LARGE BOWEL OBSTRUCTION

DOUBLE-BUBBLE SIGN. CHARACTERISTIC FOR DUODENAL ATRESISA.

AIR UNDER DIAPHRAGM PERFORATED VISCUS

MULTIPLE AIR-FLUID LEVELS (gasless pelvis). MOSTLY INTESTINAL OBSTRUCTION

MULTIPLE AIR-FLUID LEVELS (small and large bowel). MOSTLY PARALYTIC ILEUS

AIR UNDER DIAPHRAGM

Plain abdomen: Hugely dilated colon Hirschsprung disease

NORMAL Barium enema

NORMAL Barium enema

Barium enema: Dilated colon with loss of haustrations. Hallmark finding is conical transition from distal nondilated rectum to proximal dilated colon

Hirschsprung disease

Hirschsprung disease

Transition

Red arrows point to linear bands of radiolucency which parallel the wall of the bowel indicating the presence of pneumatosis intestinalis in necrotizing enterocolitis

Necrotizing enterocolitis in lateral decubitus film

HEART

Normal cardio-thoracic ratio is 1:2 (50%)

Cardiomegaly
Lobar pneumonia

Differential diagnosis of cardiomegaly

Most important causes are:
 Pericardial effusion  Dilated cardiomyopathy  Rheumatic H.D. with multi-valvular affection  Congestive heart failure.

COMMENT:
Pulmonary oligemia. Small-sized heart with right ventricular (supra-diaphragmatic apex). The left cardio-phrenic angle is acute. Heart is characteristically BOOTSHAPED. (Coeur en Sabot Sign). These findings are highly suggestive of  TETRALOGY OF FALLOT

DIAGNOSIS: Tetralogy of Fallot (TOF) - Coeur en Sabot Sign

Bilateral pulmonary venous congestion

Bilateral pulmonary edema

Huge Cardiomegaly. The heart is flask-shaped and well-delineated. Mostly pericardial effusion.

THANK YOU