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Chapter 8. Chest X-Ray Atlas

425

Chapter 8

CHEST X-RAY ATLAS

Burke A. Cunha, MD

Douglas S. Katz, MD

Robert Moore, MD

Daniel S. Siegal, MD

Chest X-Ray Patterns

Unilateral Focal Segmental/Lobar Infiltrate Without Effusion 426 Unilateral Focal Segmental/Lobar Infiltrate With Effusion 431 Unilateral Ill-Defined Infiltrates Without Effusion 436 Unilateral Ill-Defined Infiltrates With Effusion 443 Bilateral Infiltrates Without Effusion 448 Bilateral Infiltrates With Effusion 458 Cavitary Infiltrates (Thick-Walled) 463 Cavitary Infiltrates (Thin-Walled) 470 References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . 473

This atlas has been developed to assist in the management of patients who present with respiratory symptoms and chest x-ray abnormalities. Eight common chest x-ray patterns are provided. Common infections and noninfectious etiologies are followed by usual clinical features, which can be used to identify the disorder and help guide empiric/specific therapy.

426	A n t i b i o t i c E s s e n t i a l s

UNILATERAL FOCAL SEGMENTAL/LOBAR

INFILTRATE WITHOUT EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

S. pneumoniae	Elderly,	Fever, chills,	↑WBC, ↓ platelets	Consolidation
	smokers,	no relative	(overwhelming	usually limited
	COPD, ↓	bradycardia.	infection/	to one lobe (RLL
	humoral	Chest signs	hyposplenism),	most common) ±
	immunity	related to	normal LFTs. Sputum	air bronchogram.
	(multiple	extent of	with abundant PMNs	Pleural effusion
	myeloma, SLE,	consolidation.	and gram-positive	very uncommon.
	CLL,		diplococci. Blood	Empyema not
	hyposplenism).		cultures usually	uncommon. No
			positive.	cavitation.

H. influenzae	Recent contact	Fever, chills.	↑ WBC. Sputum/	Usually RLL with
	with H.		pleural effusion	small/moderate
	influenzae URI.		with gram-negative	effusion. No
			pleomorphic bacilli.	empyema. No
			Blood cultures often	cavitation.
			positive.

Chapter 8. Chest X-Ray Atlas

427

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

M. catarrhalis	Chronic/heavy	Nonspecific.	Sputum with gram-	Usually
	smoker, COPD.		negative/variable	lower lobe ±
			diplococci. Blood	consolidation. No
			cultures negative.	pleural effusion
				or cavitation.

K. pneumoniae	Nosocomial	Fever, chills,	↑ WBC, ↓ platelets,	“Bulging fissure”
	pneumonia	signs of alcoholic	↑ SGOT/SGPT (2°	sign secondary
	or history of	cirrhosis, signs	to alcoholism).	to expanded
	alcoholism in	of consolidation	“Red currant jelly”	lobar volume.
	patient with	over involved	sputum with	Empyema
	community-	lobe.	PMNs and plump	rather than
	acquired		gram-negative	pleural effusion.
	pneumonia.		encapsulated bacilli.	Cavitation in
				5–7 days (thick
				walled).

Legionella	Recent contact	Fever/chills,	↑WBC, ↑ SGOT/SGPT,	Rapidly
	with Legionella	relative	↓ PO =, ↓ Na+, ↑ CPK,	progressive
			4
	containing	bradycardia.	↑ ESR, ↑ CRP, ↑ ferritin	asymmetrical
	water. Usually	Hepatic/splenic	levels, microscopic	infiltrates clue
	elderly. May have	enlargement	hematuria,	to Legionella.
	watery diarrhea,	goes against	L. pneumophila	Consolidation
	abdominal	the diagnosis.	antigenuria	and pleural
	pain, mental	↓ breath sounds	(serotypes 01–06	effusion not
	confusion.	if consolidation	only) may not be	uncommon.
		or pleural	positive early.	Cavitation rare.
		effusion.	Mucoid/purulent
			sputum with few
			PMNs. Sputum
			culture for Legionella
			or sputum DFA
			(before therapy)
			is diagnostic.
			↑ Legionella titer
			≥ 1:256 or ≥ 4-fold
			rise between acute
			and convalescent
			titers.

428 A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Psittacosis	Recent bird	Fever/chills,	↑/normal WBC,	Dense infiltrate.
	contact with	± relative	↑ LFTs. Sputum with	Consolidation
	psittacine birds.	bradycardia,	few PMNs. ↑	common.
	Severe headache.	Horder’s spots	C. psittaci titers.	Pleural effusion/
		on face, epistaxis,		cavitation rare.
		± splenomegaly.
		Signs of
		consolidation
		common.

Q fever	Recent contact	Fever/chills,	↑/normal WBC,	Dense
	with sheep or	± relative	↑ LFTs. Sputum	consolidation.
	parturient cats.	bradycardia,	with no bacteria/	Cavitation/
		splenomegaly, ±	few PMNs (caution–	pleural effusion
		hepatomegaly.	biohazard). Acute Q	rare.
			fever with ↑ in phase
			II ELISA antigens.

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Atelectasis	Ineffectual moist	Fevers ≤ 102°F.	↑ WBC (left shift),	Segmental infiltrate.
	recurrent cough	If large, signs	normal platelets.	RUL/RML atelectasis
	characteristic of	of volume loss	Other lab results	obscures right
	post-operative	(↓ respiratory	related to	heart border. In LUL
	atelectasis.	excursion,	underlying cause	atelectasis, may be
		↑ diaphragm,	of atelectasis.	triangular infiltrate
		mediastinum		extending to upper
		shift toward		anterior mediastinum
		affected side).		mimicking
		If small, ↓		malignancy. LLL
		breath sounds		atelectasis causes
		over affected		↑ density of heart
		segment/lobe.		shadow. No cavitation
				or pleural effusion.

Chapter 8. Chest X-Ray Atlas

429

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Pulmonary	Acute onset	↑ pulse/	↑ fibrin split	Normal or show non-
embolus/	dyspnea/	respiratory rate.	products and	specific pleural-based
infarct	pleuritic chest		D-dimers ±	infiltrates resembling
	pain. History of		↑ total bilirubin.	atelectasis. Focal
	lower extremity		Bloody pleural	segmental/lobar
	trauma, stasis or		effusion. ECG	hyperlucency
	hypercoagulable		with RV strain/P-	(Westermark’s sign)
	disorder.		pulmonale	in some. “Hampton’s
			(large embolus).	hump” with infarct.
			Positive V/Q	Resolving infarcts ↓
			scan and CT	in size but maintain
			pulmonary	shape/density
			angiogram.	(“melting ice cube”).

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC,	Unilateral or
	with weight loss,	splenomegaly.	↑ basophils,	asymmetrical
	night sweats,		↑ eosinophilia,	bilateral hilar
	fatigue.		↓ lymphocytes,	adenopathy. Lung
			↑ platelets,	infiltrate may appear
			↑ ESR, ↑ alkaline	contiguous with hilar
			phosphatase,	adenopathy. No clear
			↑ 1, 2 globulins	channel between
			on SPEP.	mediastinum and
				hilar nodes. Small
				pleural effusions rare.

Alveolar cell	Fever, ↑ appetite	± dullness over	Positive cytology	Well/ill-defined
carcinoma	with weight loss,	lobe with large	by BAL/lung	circumscribed
	night sweats.	lower lobe	biopsy.	peripheral infiltrates
		lesions.		± air bronchograms.
				May be multifocal/
				multilobar. Hilar
				adenopathy present.
				Stranding to the
				hilum (“pleural tail”
				sign). ± pleural
				effusion if lower
				lobe infiltrate. No
				cavitation.

430	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Aspiration	Swallowing	Unremarkable.	↑ WBC, ↑ ESR.	Infiltrate usually
pneumonia	disorder 2° to			involves superior
	CNS/GI disorder;			segments of lower
	impaired			lobes (or posterior
	consciousness;			segments of upper
	recent aspiration			lobes if aspiration
	2° to dental,			occurred supine).
	upper GI, or			Focal infiltrate
	pulmonary			initially, which may
	procedure.			be followed in 7 days
				by cavitation/lung
				abscess.

Chapter 8. Chest X-Ray Atlas

431

UNILATERAL FOCAL SEGMENTAL/LOBAR

INFILTRATE WITH EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Klebsiella	Nosocomial	Fever, chills,	↑ WBC, ↓ platelets,	“Bulging fissure”
pneumoniae	pneumonia	signs of	SGOT/SGPT (2° to	sign secondary to
	or history of	alcoholic	alcoholism). “Red	expanded lobar
	alcoholism in	cirrhosis,	currant jelly“ sputum	volume. Empyema
	patient with	signs of	with PMNs and	rather than pleural
	community-	consolidation	plump gram-negative	effusion. Usually
	acquired	over involved	encapsulated bacilli.	cavitation in 5–7 days
	pneumonia.	lobe.		(thick walled).

H. influenzae	Recent contact	Fever, chills.	↑ WBC. Sputum/	Usually RLL with small/
	with H.		pleural effusion	moderate effusion.
	influenzae URI.		with gram-negative	No empyema. No
			pleomorphic bacilli.	cavitation.
			Blood cultures often
			positive.

432	A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

TB (primary)	Recent TB	Unilateral	PPD (–)/anergic.	Lower lobe infiltrate
	contact.	lower lobe	Exudative pleural	with small/moderate
		dullness	effusion (pleural fluid	pleural effusion.
		related to	with ↑ lymphocytes, ↑	No cavitation or
		size of pleural	glucose, ± RBCs).	apical infiltrates.
		effusion.		Hilar adenopathy
				asymmetrical when
				present.

Coccidio-	Previous	± E. nodosum.	Normal WBC, no	Thick/thin-walled
mycosis	exposure		eosinophilia in	cavities < 3 cm ±
(chronic)	in endemic		chronic phase.	calcifications. Air
	coccidiomycosis		Complement	fluid level rare
	areas.		fixation IgG titer ≥	unless secondarily
	Asymptomatic.		1:32 indicates active	infected. Cavities
			disease.	usually in anterior
				segments of upper
				lobes (vs. posterior
				segments with TB).
				No surrounding tissue
				reaction. Pleural
				effusion common.

Tularemia	History of recent	Fever, chills,	Normal/↑ WBC,	Pleural effusion ± hilar
	deer fly, rabbit,	no relative	normal LFTs.	adenopathy.
	or tick exposure.	bradycardia.	Sputum/pleural
	Tularemia	Chest findings	effusion with gram-
	pneumonia may	related to	negative coccobacilli
	complicate any	extent of	(caution–biohazard).
	of the clinical	infiltrate/	Bloody pleural
	presentations of	consolidation	effusion. Tularemia
	tularemia.	and pleural	serology with
		effusion.	↑ microagglutination
			titer ≥ 1:160 acutely
			and ≥ 4-fold rise
			between acute and
			convalescent titers.

Chapter 8. Chest X-Ray Atlas

433

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Adenovirus	Recent URI.	Fever, chills,	↑ adenoviral	III-defined infiltrate(s)
		myalgias. Sore	titers and positive	without cavitation ±
		throat and	adenoviral cultures of	pleural effusion.
		conjunctivitis	respiratory secretions.
		not always	Respiratory viral FA
		present with	panel + for
		adenoviral	adenovirus.
		pneumonia.
		Chest exam
		± signs of
		consolidation.

Legionella	Recent contact	Fever/chills,	↑ WBC, ↑ SGOT/SGPT,	Rapidly progressive
	with Legionella	relative	↓ PO =, ↓ Na+, ↑ CPK,	asymmetrical infiltrates
			4
	containing	bradycardia.	↑ ESR, ↑ CRP, ↑ ferritin	clue to Legionella.
	water. Usually	Hepatic/	levels, microscopic	Consolidation and
	elderly. May	splenic	hematuria,	pleural effusion not
	have watery	enlargement	L. pneumophila	uncommon. Cavitation
	diarrhea,	goes against	antigenuria	rare.
	abdominal	the diagnosis.	(serotypes 01–06
	pain, mental	↓ breath	only) may not
	confusion.	sounds if	be positive early.
		consolidation	Mucoid/purulent
		or pleural	sputum with few
		effusion.	PMNs. Sputum
			culture for Legionella
			or sputum DFA
			(before therapy)
			is diagnostic.
			↑ Legionella titer
			≥ 1:256 or ≥ 4-fold
			rise between acute/
			convalescent titers.

Group A	Recent	Fever/chills.	↑ WBC. Pleural fluid	Unilateral infiltrate
streptococci	exposure or	Physical signs	is serosanguineous.	may be obscured by
	recent blunt	related to	Sputum/pleural fluid	large pleural effusion.
	chest trauma ±	size of pleural	with gram-positive	No empyema. No
	chest pain.	effusion.	cocci in pairs/chains.	cavitation.
			Positive pleural fluid/
			blood cultures.

434	A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Rhodococcus	Insidious	Unremarkable.	Normal/↑ WBC.	Segmental infiltrate
equi	onset of fever,		Sputum/pleural fluid	with upper lobe
	dyspnea,		with gram-positive	predominance ±
	chest pain, ±		pleomorphic weakly	cavitation. Air-fluid
	hemoptysis.		acid-fast bacilli.	levels and pleural
	Immuno-		Sputum, pleural	effusion common.
	suppressed		fluid, blood cultures
	patients with ↓		positive for R. equi.
	cell-mediated
	immunity or
	exposure to
	cattle, horses,
	pigs.

Noninfectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Pulmonary	Acute onset	↑ pulse/	↑ fibrin split	Normal or show
embolus/	dyspnea/	respiratory rate.	products and	non-specific pleural-
infarct	pleuritic chest		D-dimers ± ↑ total	based infiltrates
	pain. History of		bilirubin. Bloody	resembling atelectasis.
	lower extremity		pleural effusion.	Focal segmental/
	trauma, stasis or		ECG with RV	lobar hyperlucency
	hypercoagulable		strain/P-pulmonale	(Westermark’s sign)
	disorder.		(large embolus).	in some.“Hampton’s
			Positive V/Q scan	hump” with infarct.
			and CT pulmonary	Resolving infarcts ↓ in
			angiogram.	size but maintain shape/
				density (“melting ice
				cube”).

Chapter 8. Chest X-Ray Atlas

435

Noninfectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC,	Unilateral or
	with weight loss,	splenomegaly.	↑ basophils,	asymmetrical bilateral
	night sweats,		↑ eosinophilia,	hilar adenopathy. Lung
	fatigue.		↓ lymphocytes,	infiltrate may appear
			↑ platelets,	contiguous with hilar
			↑ ESR, ↑ alkaline	adenopathy. No clear
			phosphatase,	channel between
			↑ 1,2 globulins on	mediastinum and hilar
			SPEP.	nodes. Small pleural
				effusions rare.

Alveolar cell	Fever, ↑ appetite	± dullness over	Positive cytology	Well/ill-defined
carcinoma	with weight loss,	lobe with large	by BAL/lung	circumscribed
	night sweats.	lower lobe	biopsy.	peripheral infiltrates
		lesions.		± air bronchograms.
				May be multifocal/
				multilobar. Hilar
				adenopathy present.
				Stranding to the hilum
				(“pleural tail” sign).
				± pleural effusion if
				lower lobe infiltrate. No
				cavitation.

Radiation	History of mantle	Nonspecific.	Nonspecific.	Symmetrical infiltrates
pneumonitis	radiation for			in the distribution of
	lymphoma, lung			radiation therapy after
	cancer, or breast			1 month. Infiltrates
	cancer.			have “straight edges”±
				air bronchograms.
				Fibrosis common over
				radiation field after
				9–12 months. Usually
				no pleural effusions
				(small, if present).

436	A n t i b i o t i c E s s e n t i a l s

UNILATERAL ILL-DEFINED INFILTRATES

WITHOUT EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Mycoplasma	Prolonged dry/	Usually fevers	Normal/↑ WBC;	III-defined
pneumoniae	nonproductive	≤102°F without	normal platelets,	usually lower
	cough. No	relative	LFTs, PO =, CPK. ↑	lobe indistinct
			4
	laryngitis. Mild	bradycardia.	cold agglutinins	infiltrates. No
	sore throat/ear.	Myalgias, bullous	(early). ↑ IgM (not	consolidation
	Watery diarrhea.	myringitis or	IgG) Mycoplasma	or air
		otitis, non-	pneumoniae titers.	bronchograms.
		exudative	Respiratory	Small/no pleural
		pharyngitis,	secretions	effusion.
		E. multiforme.	culture positive
		Chest exam with	for Mycoplasma
		rales and no signs	pneumoniae.
		of consolidation
		or effusion.

Chapter 8. Chest X-Ray Atlas

437

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Chlamydophilia	Prolonged	Low-grade	↑ WBC, normal	III-defined,
(Chlamydia)	“mycoplasma-	fevers, myalgias,	platelets, normal LFTs.	usually lower
pneumoniae	like” illness with	non-exudate	No cold agglutinins.	lobe indistinct
	laryngitis.	pharyngitis,	↑ IgM (not IgG)	infiltrate(s).
		laryngitis.	C. pneumoniae titers.	May be “funnel
		No relative	Respiratory secretions	shaped.” No
		bradycardia,	culture positive for	consolidation,
		ear findings, or	C. pneumoniae.	cavitation, or
		rash. Chest exam		pleural effusion.
		without signs of
		consolidation or
		pleural effusion.

Adenovirus	Recent URI.	Fever, chills,	↑ adenoviral titers and	III-defined
		myalgias. Sore	positive adenoviral	infiltrate(s)
		throat and	cultures of respiratory	without
		conjunctivitis not	secretions. Respiratory	cavitation ±
		always present	viral FA panel + for	pleural effusion.
		with adenoviral	adenovirus.	Only viral cause
		pneumonia.		of focal lobar
		Chest exam		pneumonia.
		± signs of
		consolidation.

Legionella	Recent contact	Fever/chills,	↑ WBC, ↑ SGOT/SGPT,	Rapidly
	with Legionella	relative	↓ PO =, ↓ Na+, ↑ CPK,	progressive
			4
	containing	bradycardia.	↑ ESR, ↑ CRP, ↑ ferritin	asymmetrical
	water. Usually	Hepatic/splenic	levels, microscopic	infiltrates clue
	elderly. May have	enlargement	hematuria,	to Legionella.
	watery diarrhea,	goes against	L. pneumophila	Consolidation
	abdominal pain,	the diagnosis.	antigenuria (serotypes	and pleural
	mental confusion.	↓ breath sounds	01–06 only) may not be	effusion not
		if consolidation	positive early. Mucoid/	uncommon.
		or pleural	purulent sputum with	Cavitation rare.
		effusion.	few PMNs. Sputum
			culture for Legionella
			or sputum DFA (before
			therapy) is diagnostic.
			↑ Legionella titer
			≥1:256 or ≥4-fold
			rise between acute/
			convalescent titers.

438 A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Psittacosis	Recent bird	Fever/chills,	↑/normal WBC, ↑ LFTs.	Dense infiltrate.
	contact with	± relative	Sputum with few	Consolidation
	psittacine birds.	bradycardia, ±	PMNs. ↑ C. psittaci	common.
	Severe headache.	Horder’s spots on	titers.	Pleural effusion/
		face, epistaxis,		cavitation rare.
		± splenomegaly.
		Signs of
		consolidation
		common.

Q fever	Recent contact	Fever/chills,	↑/normal WBC, ↑ LFTs.	Dense
	with sheep or	± relative	Sputum with no	consolidation.
	parturient cats.	bradycardia,	bacteria/few PMNs	Cavitation/
		splenomegaly,	(caution–biohazard).	pleural effusion
		± hepatomegaly.	Acute Q fever with ↑ in	rare.
			phase II ELISA antigens.

Nocardia	Fevers, night	Unremarkable.	Normal/↑ WBC, ↑ ESR.	Dense large
	sweats, fatigue,		Sputum with gram-	infiltrates.
	↓ cell-mediated		positive AFB.	May cavitate
	immunity (e.g.,			and mimic TB,
	HIV, organ			lymphoma, or
	transplants, PAP,			squamous cell
	immunosup			carcinoma. No
	pressive therapy).			calcification ±
				pleural effusion.

Actinomycosis	Recent dental	± chest wall sinus	Normal/↑ WBC, ↑ ESR.	Dense infiltrates
	work.	tracts.	Sputum with gram-	extending
			positive filamentous	to chest
			anaerobic bacilli.	wall. No hilar
				adenopathy.
				Cavitation
				rare. ± pleural
				effusion rare.

Chapter 8. Chest X-Ray Atlas

439

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Cryptococcus	Exposure to air	Unremarkable.	Normal WBC.	Dense lower
neoformans	conditioner or		Cryptococcal serology	nodular mass
	pigeons.		with ↑ C. neoformans	lesions. No
			antigen levels.	calcification or
				cavitation. ±
				pleural effusion.

Aspiration	Swallowing	Unremarkable.	↑ WBC, ↑ ESR.	Infiltrate
pneumonia	disorder 2° to			usually involves
	CNS/GI disorder;			superior
	impaired			segments of
	consciousness;			lower lobes
	recent aspiration			(or posterior
	2° to dental,			segments of
	upper GI, or			upper lobes
	pulmonary			if aspiration
	procedure.			occurred
				supine). Focal
				infiltrate initially,
				which may
				be followed
				in 7 days by
				cavitation/lung
				abscess.

440	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Bronchogenic	Fever, ↓ appetite	Paraneoplastic	Normal/↑ WBC, ↑	Small/squamous
carcinoma	with weight	syndromes	platelets, ↑ ESR,	cell carcinomas
	loss, cough ±	especially with	findings related	present as central
	hemoptysis.	small (oat) cell/	to underlying	lesions/hilar masses.
	Cough with	squamous cell	malignancy, ±	Adenocarcinoma/
	copious clear/	carcinoma ±	clubbing.	large cell anaplastic
	mucoid sputum	hypertrophic		carcinomas are usually
	in large cell	pulmonary		peripheral initially.
	anaplastic	osteoarthro-		“Tumor tendrils“
	carcinoma.	pathy.		extending into
	Increased risk			surrounding lung
	in smokers,			tissue is characteristic.
	aluminum/			No calcifications
	uranium miners,			(may be present on
	cavitary lung			chest CT). Cavitation
	disease (adeno-			with squamous cell
	carcinoma),			carcinoma. ± pleural
	previous			effusions.
	radiation therapy
	from lymphoma/
	breast cancer.

Lymphangitic	History of breast,	Findings	Normal/↑ WBC,	Interstitial indistinct
metastases	thyroid, pancreas,	related to	↑ ESR.	pulmonary
	cervical,	underlying		infiltrates (may be
	prostate, or lung	malignancy.		reticulonodular)
	carcinoma.			with lower lobe
				predominance
				Usually unilateral
				but may be bilateral.
				No consolidation or
				cavitation ± pleural
				effusions.

Lung contusion	Recent closed	Chest wall	↑ WBC (left shift).	Patchy ill-defined
	chest trauma,	contusion over		infiltrate(s) ±
	chest pain.	infiltrate.		rib fractures/
				pneumothorax in area
				of infiltrate. Infiltrate
				clears within 1 week.

Chapter 8. Chest X-Ray Atlas

441

Noninfectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Congestive	Coronary heart	No/low-grade	↑ WBC (left shift),	Cardiomegaly, pleural
heart failure	disease, valvular	fevers ↑ pulse	normal platelets,	effusion (R > [R + L] >
	heart disease,	and respiratory	mildly ↑ SGOT/	L). Kerley B lines with
	cardiomyopathy.	rate, positive	SGPT.	vascular redistribution
		jugular venous		to upper lobes.
		distension and		Typically bilateral
		hepatojugular		rather than unilateral.
		reflex, cardio-
		megaly,
		S3, ascites,
		hepatomegaly,
		pedal edema.

Alveolar cell	Fever, ↑ appetite	± dullness over	Positive cytology	Well/ill-defined
carcinoma	with weight loss,	lobe with large	by BAL/lung	circumscribed
	night sweats.	lower lobe	biopsy.	peripheral infiltrates
		lesions.		± air bronchograms.
				May be multifocal/
				multilobar. Hilar
				adenopathy present.
				Stranding to the
				hilum (“pleural tail”
				sign). ± pleural
				effusion if lower
				lobe infiltrate. No
				cavitation.

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC,	Unilateral or
	with weight loss,	splenomegaly.	↑ basophils,	asymmetrical bilateral
	night sweats,		↑ eosinophilia,	hilar adenopathy.
	fatigue.		↓ lymphocytes,	Lung infiltrate may
			↑ platelets,	appear contiguous
			↑ ESR, ↑ alkaline	with hilar adenopathy.
			phosphatase,	No clear channel
			↑ 1,2 globulins on	between media-
			SPEP.	stinum and hilar
				nodes. Small pleural
				effusions rare.

442	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Pulmonary	History of closed	↑ WBC	Anemia plus	Localized or
hemorrhage	chest trauma	(left shift),	findings secondary	diffuse fluffy
	or hemorrhagic	↑ pulse rate,	to underlying	alveolar infiltrate(s).
	disorder.	respiratory rate.	hemorrhagic	No cavitation,
		Signs of closed	disorder.	consolidation, or
		chest trauma.		effusion.

Systemic lupus	Fatigue, chest	Fever/myalgias,	↑ ANA, ↑ DS-DNA,	Migratory ill-defined
erythematosus	pain. History of	alopecia, malar	↓ C3, polyclonal	non-segmental
(SLE)	SLE.	rash, “cytoid	gammopathy on	infiltrates ± small
		bodies“ in	SPEP, ↑ ferritin.	pleural effusions.
		retina, painless	Pleural fluids with	No consolidation or
		oral ulcers,	↑ ANA, ↓ C3.	cavitation.
		synovitis,
		splenomegaly,
		generalized
		adenopathy,
		Raynaud’s
		phenomenon.

Aspiration	Swallowing	Unremarkable.	↑ WBC, ↑ ESR.	Infiltrate usually
pneumonia	disorder 2° to			involves superior
	CNS/GI disorder;			segments of lower
	impaired			lobes (or posterior
	consciousness;			segments of upper
	recent aspiration			lobes if aspiration
	2° to dental,			occurred supine).
	upper GI, or			Focal infiltrate
	pulmonary			initially, which may
	procedure.			be followed in 7 days
				by cavitation/lung
				abscess.

Chapter 8. Chest X-Ray Atlas

443

UNILATERAL ILL-DEFINED INFILTRATES

WITH EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

TB (primary)	Recent TB contact.	Unilateral	PPD anergic.	Lower lobe
		lower lobe	Exudative pleural	infiltrate with
		dullness	effusion (pleural fluid	small/moderate
		related to	with ↑ lymphocytes,	pleural effusion.
		size of pleural	↑ glucose, ± RBCs).	No cavitation or
		effusion.		apical infiltrates.
				Hilar adenopathy
				asymmetrical when
				present.

Nocardia	Fevers, night sweats,	Unremarkable.	Normal/↑ WBC,	Dense large
	fatigue, ↓ cell-		↑ ESR. Sputum with	infiltrates. May
	mediated immunity		gram-positive AFB.	cavitate and mimic
	(e.g., HIV, organ			TB, lymphoma,
	transplant, PAP,			or squamous cell
	immuno-suppressive			carcinoma. No
	therapy).			calcification ±
				pleural effusion.

444 A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Legionella	Recent contact	Fever/chills,	↑ WBC, ↑ SGOT/SGPT,	Rapidly progressive
	with Legionella	relative	↓ PO =, ↓ Na+, ↑ CPK,	asymmetrical
			4
	containing water.	bradycardia.	↑ ESR, ↑ CRP, ↑ ferritin	infiltrates clue
	Usually elderly. May	Hepatic/	levels, microscopic	to Legionella.
	have watery diarrhea,	splenic	hematuria,	Consolidation and
	abdominal pain,	enlargement	L. pneumophila	pleural effusion
	mental confusion.	goes against	antigenuria	not uncommon.
		the diagnosis.	(serotypes	Cavitation rare.
		↓ breath	01–06 only) may
		sounds if	not be positive early.
		consolidation	Mucoid/purulent
		or pleural	sputum with few
		effusion.	PMNs. Sputum
			culture for Legionella
			or sputum DFA
			(before therapy)
			is diagnostic.
			↑ Legionella titer
			≥1:256 or ≥4-fold
			rise between acute/
			convalescent titers.

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Lymphangitic	History of breast,	Findings related	Normal/	Interstitial indistinct
metastases	thyroid, pancreas,	to underlying	↑ WBC, ↑ ESR.	pulmonary
	cervical,	malignancy.		infiltrates (may be
	prostate, or lung			reticulonodular)
	carcinoma.			with lower lobe
				predominance
				Usually unilateral
				but may be bilateral.
				No consolidation or
				cavitation ± pleural
				effusions.

Chapter 8. Chest X-Ray Atlas

445

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Pulmonary	Acute onset	↑ pulse/	↑ fibrin split	Normal or show
embolus/	dyspnea/	respiratory rate.	products and	non-specific pleural-
infarct	pleuritic chest		D-dimers ± ↑	based infiltrates
	pain. History of		total bilirubin.	resembling
	lower extremity		Bloody pleural	atelectasis. Focal
	trauma, stasis or		effusion. ECG	segmental/lobar
	hypercoagulable		with RV strain/	hyperlucency
	disorder.		P-pulmonale	(Westermark’s sign)
			(large embolus).	in some. “Hampton’s
			Positive V/Q	hump“ with infarct.
			scan and CT	Resolving infarcts ↓
			pulmonary	in size but maintain
			angiogram.	shape/density
				(“melting ice cube“).

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC,	Unilateral or
	with weight loss,	splenomegaly.	↑ basophils,	asymmetrical
	night sweats,		↑ eosinophilia,	bilateral hilar
	fatigue.		↓ lymphocytes,	adenopathy. Lung
			↑ platelets, ↑ ESR,	infiltrate may appear
			↑ alkaline	contiguous with
			phosphatase,	hilar adenopathy.
			↑ 1,2 globulins on	No clear channel
			SPEP.	between
				mediastinum and
				hilar nodes. Small
				pleural effusions
				rare.

446	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Bronchogenic	Fever, ↓ appetite	Paraneoplastic	Normal/↑ WBC,	Small/squamous
carcinoma	with weight	syndromes	↑ platelets, ↑ ESR,	cell carcinomas
	loss, cough ±	especially with	findings related	present as central
	hemoptysis.	small (oat) cell/	to underlying	lesions/hilar masses.
	Cough with	squamous cell	malignancy, ±	Adenocarcinoma/
	copious clear/	carcinoma ±	clubbing.	large cell anaplastic
	mucoid sputum	hypertrophic		carcinomas are
	in large cell	pulmonary		usually peripheral
	anaplastic	osteoarthropathy.		initially. “Tumor
	carcinoma.			tendrils” extending
	Increased risk			into surrounding
	in smokers,			lung tissue is
	aluminum/			characteristic. No
	uranium miners,			calcifications (may
	cavitary lung			be present on chest
	disease (adeno-			CT). Cavitation
	carcinoma),			with squamous cell
	previous			carcinoma. ± pleural
	radiation therapy			effusions.
	from lymphoma/
	breast cancer.

Alveolar cell	Fever, ↑ appetite	± dullness over	Positive cytology	Well/ill-defined
carcinoma	with weight loss,	lobe with large	by BAL/lung	circumscribed
	night sweats.	lower lobe lesions.	biopsy.	peripheral infiltrates
				± air bronchograms.
				May be multifocal/
				multilobar. Hilar
				adenopathy
				present. Stranding
				to the hilum
				(“pleural tail” sign).
				± pleural effusion if
				lower lobe infiltrate.
				No cavitation.

Chapter 8. Chest X-Ray Atlas

447

Noninfectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Metastatic	History of breast,	Findings related	Secondary to	Nodular lesions
carcinoma	thyroid, renal	to underlying	effects of primary	that vary in size.
	cell, colon,	malignancy and,	neoplasm,	Metastatic lesions
	pancreatic cancer	when present, to	metastases,	are usually well
	or osteogenic	bone, hepatic, CNS	paraneoplastic	circumscribed
	sarcoma.	metastases.	syndrome.	with lower lobe
				predominance.
				Usually no bronchial
				obstruction
				(obstruction
				suggests colon,
				renal, or melanoma
				metastases).
				Usually no
				cavitation (except
				for squamous
				cell metastases).
				Calcification
				usually suggests
				osteosarcoma (rarely
				adenocarcinoma).
				Pleural effusion rare
				(except for breast
				cancer).

448	A n t i b i o t i c E s s e n t i a l s

BILATERAL INFILTRATES

WITHOUT EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Influenza	Acute onset of fever,	↑ respiratory	↓ WBC,	Early normal/
(human, avian,	myalgias, headache,	rate, cyanosis in	↓ platelets, few/	near normal
swine)	fatigue, sore throat,	severe cases.	no atypical	appearance.
	rhinorrhea, dry cough,		lymphocytes,	(< 48 hours) Later
	± pleuritic chest pain.		↑ A-a gradient.	(> 48 hours)
			Influenza in	diffuse patchy
			respiratory	bilateral interstitial
			secretions by	infiltrates. No
			culture/viral FA	focal/segmental
			panel.	infiltrates unless
				secondary bacterial
				pneumonia
				present. ±small
				pleural effusions.

Chapter 8. Chest X-Ray Atlas

449

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

MERS	Acute onset of fever/	Early fulminant	(N) WBC	Unilateral/bilateral
	chills, headache,	respiratory	lymphopenia/	interstitial, nodule
	myalgias, dry cough ±	failure.	lymphocytosis,	dense infiltrate.
	N/V/D		↑ LDH
			↑ LFTs	Consolidation
	Malaise; Hemoptysis		MERS-Cov	common/± pleural
			in lower	effusions.
			respiratory
			secretions.

SARS	Acute onset of fever/	↑ respiratory	N/↓ WBC,	Bilateral
	chills, headache	rate, SOB in	lymphopenia,	symmetrical
	myalgias, dry cough ±	severe cases.	↓ platelets,	patchy infiltrates.
	N/V/D.		↑ LDH, ↑ LFTs,	Consolidation
	Biphasic illness		↓ pO2, ↑ A-a	uncommon. No
	Biphasic illness		gradient.	cavitation or
			SARS – CoV	effusion.
			in respiratory
			secretions.

HSV-1	Fever. Often presents	Unremarkable.	↑ WBC, ↓ pO2,	Minimal bilateral
	in normal hosts as		↑ A-a gradient.	diffuse infiltrates
	“failure to wean” from		Cytology +	without cavitation
	ventilator.		for cytopathic	or effusion.
			effects (CPE) of
			HSV.
RSV	Recent URI contact,	Mild lower	Normal WBC;	Near normal chest
	dry cough, wheezing.	respiratory	↓ pO2/↑ A-a	x-ray or bilateral
		tract infection	gradient in	symmetrical
		in normal host.	severe RSV. RSV	patchy infiltrates.
		Moderate/severe	in respiratory	Consolidation
		pneumonia	secretions by	uncommon. No
		in organ	culture/viral FA	cavitation or
		transplants.	panel.	effusion.
VZV	VZV pneumonia	Healing vesicles,	↑ WBC,	Minimal diffuse
	occurs 2–3 days	dry cough. Mild	↑ platelets,	fluffy interstitial
	after rash. ↑ risk with	pneumonia in	↑ basophils;	infiltrates. Diffuse
	pregnancy, smoking.	normal hosts.	↓ pO2/↑ A-a	small calcifications
		Moderate/	gradient	may develop
		severe	in severe	years later. No
		pneumonia	chickenpox	calcification of
		in organ	pneumonia.	hilar nodes (in
		transplants.	↑ VZV titers.	contrast to TB/
				histoplasmosis).

450	A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

CMV	↓ cell-mediated	Fever ≤ 102°F.	↓ pO2, ↑ A-a	Most HIV patients
	immunity (HIV,		gradient, ↑ LDH	with PCP also have
	organ transplants,		(PCP). PCP cysts	underlying CMV.
	immunosuppressive		or CMV “Cowdry	Organ transplants
	therapy). Increasing		Owl eye”	with CMV usually
	dyspnea over 1 week.		inclusion bodies	do not have
			in respiratory	underlying PCP.
			secretions or
			transbronchial/
			open lung
			biopsy.

P (carinii)	↓ cell-mediated	↓ breath sounds	Normal/↑ WBC	Bilateral perihilar
jiroveci (PCP)	immunity (e.g., HIV,	bilaterally.	(left shift),	symmetrical
	immuno-suppressive	Other findings	↑ lymphocytes,	patchy infiltrates
	therapy). Increasing	depend on	↑ LDH. ↓ pO2,	± pneumothorax.
	dyspnea over 1	size/location of	↓ DLCO, ↑ A-a	No calcification,
	week. Chest pain	pneumothorax	gradient. PCP	cavitation, or
	with shortness of	(if present).	cysts in sputum/	pleural effusion.
	breath suggests		respiratory
	pneumothorax.		secretions.

TB	Fevers, night sweats,	± bilateral apical	Normal WBC,	Slowly progressive
(reactivation)	normal appetite with	dullness.	↑ platelets,	bilateral infiltrates.
	weight loss, cough ±		↑ ESR (≤ 70	No pleural effusion.
	hemoptysis.		mm/h). Positive	Usually in apical
			PPD. AFB in	segment of lower
			sputum smear/	lobes or apical/
			culture.	posterior segments
				of upper lobes.
				Calcifications
				common.

Chapter 8. Chest X-Ray Atlas

451

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Legionella	Recent contact with	Fever/chills,	↑ WBC, ↑ SGOT/	Rapidly progressive
	Legionella containing	relative	SGPT, ↑ pO =,	asymmetrical
			4
	water. Usually elderly.	bradycardia.	↓ Na+, ↑ CPK,	infiltrates clue
	May have watery	Hepatic/splenic	↑ ESR, ↑ CRP,	to Legionella.
	diarrhea, abdominal	enlargement	↑ ferritin levels,	Consolidation and
	pain, mental	goes against	microscopic	pleural effusion
	confusion.	the diagnosis.	hematuria,	not uncommon.
		↓ breath sounds	L. pneumophila	Cavitation rare.
		if consolidation	antigenuria
		or pleural	(serotypes
		effusion.	01–06 only) may
			not be positive
			early. Mucoid/
			purulent
			sputum with
			few PMNs.
			Sputum culture
			for Legionella
			or sputum DFA
			(before therapy)
			is diagnostic.
			↑ Legionella
			titer ≥ 1:256
			or ≥ 4-fold rise
			between acute/
			convalescent
			titers.

Psittacosis	Recent bird contact	Fever/chills,	↑/normal WBC,	Dense infiltrate.
	with psittacine birds.	± relative	↑ LFTs. Sputum	Consolidation
	Severe headache.	bradycardia,	with few PMNs.	common.
		± Horder’s	Positive	Pleural effusion/
		spots on face,	C. psittaci	cavitation rare.
		epistaxis, ±	serology.
		splenomegaly.
		Signs of
		consolidation
		common.

452 A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Q fever	Recent contact with	Fever/chills,	↑/normal	Dense
	sheep or parturient	± relative	WBC, ↑ LFTs.	consolidation.
	cats.	bradycardia,	Sputum with	Cavitation/pleural
		splenomegaly,	no bacteria/few	effusion rare.
		± hepatomegaly.	PMNs (caution–
			biohazard).
			Acute Q fever
			with ↑ in
			phase II ELISA
			antigens.

Nosocomial	Fever/pulmonary	Bilateral rales	↑WBC (left	Bilateral
pneumonia	symptoms ≥ 7 days	± purulent	shift). Blood	symmetrical diffuse
(hema-	in hospital. Increased	respiratory	cultures positive	infiltrates. May be
togenous)	risk with antecedent	secretions	for pulmonary	focal/ segmental
	heart failure in	(tracheo-	pathogens.	in aspiration
	previous 1–2 weeks.	bronchitis).	Respiratory	nosocomial
			secretions with	pneumonia. ↑ lung
			WBCs ±cultures	volumes (vs. ARDS).
			positive for	Klebsiella cavitation
			P. aeruginosa,	in 3–5 days;
			Acinetobacter,	P. aeruginosa
			Enterobacter,	cavitation in 72
			Klebsiella,	hours. No pleural
			or Serratia	effusion.
			(represents
			colonization, not
			lower respiratory
			tract/lung
			pathogens).
			Definitive
			diagnosis by
			lung biopsy/
			culture.

Chapter 8. Chest X-Ray Atlas

453

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Adult	Intubated on	± rales.	↑ WBC (left	Bilateral fluffy infiltrates
respiratory	ventilator, multi-		shift), normal	appearing ≥ 12
distress	organ system		ESR, ↓ pO2,	hours after profound
syndrome	failure.		↓ DLCO, ↑ A-a	hypoxemia. No
(ARDS)			gradient.	cardiomegaly or pleural
				effusion. Reduced lung
				volumes (vs. nosocomial
				pneumonia or CHF).
				Bilateral consolidation
				≥ 48 hours after
				appearance of infiltrates.

Goodpasture’s	Often preceded	Findings	↑ WBC, anemia,	Bilateral fine
syndrome	by a URI. Most	secondary to	↑ creatinine,	reticulonodular
	common in 20–	iron deficiency	urine with	infiltrates predominantly
	30 year old adults.	anemia.	RBCs/RBC	in lower lobes. No
	Fever, weight loss,		casts. Positive	cavitation.
	fatigue, cough,		pANCA. Linear
	hemoptysis,		IgG pattern
	hematuria.		on alveolar/
			glomerular
			basement
			membrane.

Wegener’s	Most common	Findings	↑ WBC, anemia,	Bilateral asymmetrical
granulo-	in middle-aged	of chronic	↑ platelets,	nodular infiltrates
matosis	adults. Cough,	sinusitis,	↑ ESR, ↑ RF,	of varying size with
	fever, fatigue.	bloody nasal	negative ANA,	irregular margins.
		discharge.	proteinuria,	Cavitation common.
			hematuria.	Inner lining of cavities
			Positive cANCA.	irregular. Air-fluid levels
				rare. ± pleural effusions.
				No calcifications.

Pulmonary	History of closed	↑ WBC (left	Anemia plus	Localized or diffuse fluffy
hemorrhage	chest trauma	shift),	findings	alveolar infiltrates. No
	or hemorrhagic	↑ pulse rate, ↑	secondary to	cavitation, consolidation,
	disorder.	respiratory rate.	underlying	or effusion.
		Signs of closed	hemorrhagic
		chest trauma.	disorder.

454	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Chronic renal	Chronic renal	Findings	Normal/↑ WBC	Bilateral symmetrical
failure	failure on dialysis.	related to	(left shift) plus	fluffy perihilar infiltrates
		uremia.	findings related	(butterfly pattern) ±
			to renal failure.	pleural effusions.
				No cardiomegaly
				(unlike CHF), but large
				pericardial effusion can
				mimic cardiomegaly.

Lung	Recent closed	Chest wall	↑ WBC (left	Patchy ill-defined
contusion	chest trauma,	contusion over	shift).	infiltrate(s) ± rib
	chest pain.	infiltrate.		fractures/pneumothorax
				in area of infiltrate.
				Infiltrate clears within
				1 week.

Fat emboli	1–2 days post-	↑ respiratory	Urinalysis	Bilateral predominantly
	long bone	rate.	with “Maltese	peripheral lower lobe
	fracture/ trauma.		crosses.”	infiltrates. Usually clears
				within 1 week.

Loeffler’s	Drug or parasitic	Unremarkable.	Normal WBC,	Characteristic
syndrome	exposure.		↑ eosinophilia,	“reversed bat-wing”
			↑ ESR.	pattern (i.e., peripheral
				infiltrates). Upper lobe
				predominance.

Sarcoidosis	Dyspena, fatigue,	Waxy/yellowish	↑ ESR,	Bilateral nodular
(Stage III)	nasal stuffiness.	papules	normal LFTs,	infiltrates of variable
		on face/	↑ creatinine	size without hilar
		upper trunk.	(if renal	adenopathy. Cavitation/
		Funduscopic	involvement),	pleural effusion rare.
		exam with	↑ ACE levels,
		“candle wax	hypercalciuria,
		drippings.“	hypercalcemia,
			polyclonal
			gammopathy
			on SPEP.
			Anergic.

Chapter 8. Chest X-Ray Atlas

455

Noninfectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Alveolar cell	Fever, ↑ appetite	± dullness over	Positive	Well/ill-defined
carcinoma	with weight loss,	lobe with large	cytology by	circumscribed
	night sweats.	lower lobe	BAL/lung	peripheral infiltrates ±
		lesions.	biopsy.	air bronchograms. May
				be multifocal/multilobar.
				Hilar adenopathy
				present. Stranding to
				the hilum (“pleural tail”
				sign). ± pleural effusion
				if lower lobe infiltrate.
				No cavitation.

Metastatic	History of breast,	Findings	Secondary	Nodular lesions that vary
carcinoma	thyroid, renal	related to	to effects	in size. Metastatic lesions
	cell, colon,	underlying	of primary	are usually well circum-
	pancreatic cancer	malignancy	neoplasm,	scribed with lower
	or osteogenic	and, when	metastases,	lobe predominance.
	sarcoma.	present,	paraneoplastic	Usually no bronchial
		to bone,	syndrome.	obstruction (obstruction
		hepatic, CNS		suggests colon, renal, or
		metastases.		melanoma metastases).
				Usually no cavitation
				(except for squamous
				cell metastases).
				Calcification usually
				suggests osteo-
				sarcoma (rarely adeno-
				carcinoma). Pleural
				effusion rare (except for
				breast cancer).

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC,	Unilateral or
	with weight loss,	splenomegaly.	↑ basophils,	asymmetrical bilateral
	night sweats,		↑ eosinophilia, ↓	hilar adenopathy. Lung
	fatigue.		lymphocytes, ↑	infiltrate may appear
			platelets,	contiguous with hilar
			↑ ESR, ↑ alkaline	adenopathy. No clear
			phosphatase,	channel between
			↑ 1, 2 globulins	mediastinum and hilar
			on SPEP.	nodes. Small pleural
				effusions rare.

456	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Leukostasis	Untreated acute	Fever, sternal	↑ WBC (≥ 100 K/	Diffuse symmetrical
(AML)	myelogenous	tenderness,	mm3) with	fluffy infiltrates without
	leukemia (AML).	petechiae,	blasts in	pleural effusion.
		ecchymosis.	peripheral
			smear/bone
			marrow,
			↓ platelets.

Drug-induced	Exposure	Unremarkable.	Normal WBC ±	Bilateral coarse
	to chemo-		↑ eosinophilia,	symmetrical patchy
	therapeutic		normal/↑	infiltrates/fibrosis ±
	agents (e.g.,		ESR/LFTs.	pleural effusions. Hilar
	BCNU, busulfan,		Eosinophils in	adenopathy only
	methotrexate,		pleural effusion.	with drug-induced
	cyclophospham-			pseudolymphoma
	ide, bleomycin) or			(secondary to dilantin).
	other drugs (e.g.,			No cavitation.
	nitro-furantoin,
	sulfasalazine,
	amiodarone,
	opiates, cocaine).

Idiopathic	Hemoptysis ±	Findings of	Iron deficiency	Diffuse, bilateral ill-
pulmonary	cough.	iron deficiency	anemia.	defined opacities
hemosiderosis		anemia.	Hemosiderin	or multiple “stellate“
(IPH)			in alveolar	shaped infiltrates that
			macrophages	clear between attacks.
			and urine.	Recent hemorrhage
				may be superimposed
				on a fine reticular
				pattern that occurs after
				repeated bleeds.

Chapter 8. Chest X-Ray Atlas

457

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Bronchiolitis	Fever, dyspnea,	Unremarkable.	↑ WBC (left	Classically bilateral
obliterans with	cough.		shift), ↑ LDH,	patchy peripheral
organizing			↓ pO2, ↑ A-a	infiltrates. Often lower
pneumonia			gradient.	lobe predominance.
(BOOP)				No cavitation or pleural
				effusion.

Pulmonary	Asymptomatic if	Unremarkable.	Normal/↑ WBC,	Bilateral granular or
alveolar	not infected with		↑ LDH.	peripheral infiltrates
proteinosis	Nocardia.			in butterfly pattern.
(PAP)				No hilar adenopathy,
				cardiomegaly, or pleural
				effusion.

458	A n t i b i o t i c E s s e n t i a l s

BILATERAL INFILTRATES

WITH EFFUSION

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Legionella	Recent contact	Fever/chills,	↑ WBC, ↑ SGOT/SGPT,	Rapidly
	with Legionella	relative	↑ PO =, ↓ Na+, ↑ CPK,	progressive
			4
	containing	bradycardia.	↑ ESR, ↑ CRP, ↑ ferritin	asymmetrical
	water. Usually	Hepatic/	levels, microscopic	infiltrates clue
	elderly. May have	splenic	hematuria, L. pneumophila	to Legionella.
	watery diarrhea,	enlargement	antigenuria (serotypes	Consolidation
	abdominal pain,	goes against	01–06 only) may not be	and pleural
	mental confusion.	the diagnosis. ↓	positive early. Mucoid/	effusion not
		breath sounds	purulent sputum with few	uncommon.
		if consolidation	PMNs. Sputum culture	Cavitation rare.
		or pleural	for Legionella or sputum
		effusion.	DFA (before therapy) is
			diagnostic. ↑ Legionella
			titer ≥1:256 or ≥4-fold
			rise between acute/
			convalescent titers.

Chapter 8. Chest X-Ray Atlas

459

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Hantavirus	Subacute onset,	↑ respiratory	↓ WBC, ↓ platelets	Large pleural
(HPS)	shortness of	rate, cyanosis	↓ pO2, ↑ A-a gradient.	effusions.
	breath, substernal	in severe cases.	↑ hantavirus titers.
	chest discomfort.
	Improvement
	followed by rapid
	deterioration.

MERS	Recent contact	Early fulminant	(N) WBC, relative	Unilateral (early)
	with MERS case or	respiratory	lymphopenia, ↑ LDH	or bilateral
	camel contact.	failure.	↑ LFTs	(late) interstitial,
			MERS-CoV in lower	nodular dense
	Acute onset		respiratory secretions.	infiltrates.
	of fever/chills,
	headache,			Recent contact
	myalgias, dry			with MERS case
	cough ± N/V/D,			or camel contact.
	Malaise, ±/
	hemoptysis			Consolidation
				common ±
				pleural effusions.

Measles	Recent airborne	Measles rash,	Normal/↑ WBC (left shift),	Bilateral
	exposure.	Koplik’s spots.	normal/↓ platelets, ↑ LFTs,	diffuse fine
			↑ CPK, normal/↓ pO2. If ↓	reticulonodular
			pO2, then ↑ A-a gradient.	infiltrates ± hilar
			↑ IgM measles titer.	adenopathy.
			Warthin-Finkeldey cells in	Lower lobe
			respiratory secretions.	predominance.
				Consolidation/
				pleural effusion
				uncommon.

Strongyl-	Strongyloides	With	↑ WBC (left shift),	Diffuse hilar
oides	exposure. 1/3	hyperinfection	↑ eosinophilia, ± anemia.	patchy infiltrates
	asymptomatic;	syndrome,	Blood/CSF cultures	without
	2/3 with fever,	fever, ↓ BP,	positive for enteric	consolidation
	dyspnea, cough.	abdominal	gram-negative bacilli.	or cavitation.
	Hyperinfection	tenderness	Rhabditiform larvae in	Eosinophilic
	syndrome with	± rebound,	sputum/stool.	pleural effusion
	abdominal pain,	± meningitis.		common.
	diarrhea ± GI bleed.

460	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Congestive	Coronary heart	No/low grade	↑ WBC (left	Cardiomegaly, pleural
heart failure	disease, valvular	fevers, ↑ pulse/	shift), normal	effusion
	heart disease,	respiratory	platelets, mildly	(R > [R + L] > L). Kerley
	cardiomyopathy.	rate, positive	↑ SGOT/SGPT.	B lines with vascular
		jugular venous		redistribution to
		distension and		upper lobes. Typically
		hepatojugular		bilateral rather than
		reflex,		unilateral.
		cardiomegaly,
		S3, ascites,
		hepatomegaly,
		pedal edema.

Chronic	Chronic renal failure	Findings	Normal/↑ WBC	Bilateral symmetrical
renal failure	on dialysis.	related to	(left shift) plus	fluffy perihilar
		uremia.	findings related	infiltrates (butterfly
			to renal failure.	pattern) ± pleural
				effusions. No
				cardiomegaly
				(unlike CHF), but
				large pericardial
				effusion can mimic
				cardiomegaly.

SLE	Fatigue, chest pain.	Fever/myalgias,	↑ ANA,	Migratory ill-defined
	History of SLE.	alopecia, malar	↑ DS-DNA,	non-segmental
		rash, “cytoid	↓ C3, polyclonal	infiltrates. No signs
		bodies“ in	gammopathy	of consolidation or
		retina, painless	on SPEP,	cavitation. ± small
		oral ulcers,	↑ ferritin.	pleural effusions.
		synovitis,	Pleural fluids
		splenomegaly,	with ↑ ANA,
		generalized	↓ C3.
		adenopathy,
		Raynaud’s
		phenomenon.

Chapter 8. Chest X-Ray Atlas

461

Noninfectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Goodpasture’s	Often preceded by a	Findings	↑ WBC, anemia,	Bilateral fine
Syndrome	URI. Most common	secondary to	↑ creatinine,	reticulonodular
	in 20–30 year	iron deficiency	urine with	infiltrates
	old adults. Fever,	anemia.	RBCs/RBC	predominantly in
	weight loss, fatigue,		casts. Positive	lower lobes. No
	cough, hemoptysis,		pANCA. Linear	cavitation.
	hematuria.		IgG pattern
			on alveolar/
			glomerular
			basement
			membrane.

Wegener’s	Most common in	Findings	↑ WBC, anemia,	Bilateral asym-
granulo-	middle-aged	of chronic	↑ platelets,	metrical nodular
matosis	adults. Cough, fever,	sinusitis,	↑ ESR, ↑ RF,	infiltrates of varying
	fatigue.	bloody nasal	negative ANA,	size with irregular
		discharge.	proteinuria,	margins. Cavitation
			hematuria.	common. Inner lining
			Positive cANCA.	of cavities irregular.
				Air-fluid levels rare. ±
				pleural effusions. No
				calcifications.

Sarcoidosis	Dyspnea, fatigue,	Waxy/yellowish	↑ ESR,	Bilateral nodular
(Stage III)	nasal stuffiness.	papules	normal LFTs,	infiltrates of variable
		on face/	↑ creatinine	size without hilar
		upper trunk.	(if renal	adenopathy.
		Funduscopic	involvement),	Cavitation/pleural
		exam with	↑ ACE levels,	effusion rare.
		“candle wax	hypercalciuria,
		drippings.“	hypercalcemia,
			polyclonal
			gammopathy
			on SPEP.
			Anergic.

462	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Lymphoma	Fever, ↓ appetite	Adenopathy ±	Normal WBC, ↑	Unilateral or
	with weight loss,	splenomegaly.	basophils,	asymmetrical
	night sweats,		↑ eosinophilia,	bilateral hilar
	fatigue.		↓ lymphocytes,	adenopathy. Lung
			↑ platelets,	infiltrate may appear
			↑ ESR, ↑ alkaline	contiguous with hilar
			phosphatase,	adenopathy. No clear
			↑ 1, 2 globulins	channel between
			on SPEP.	mediastinum and hilar
				nodes. Small pleural
				effusions rare.

Lymphangitic	History of breast,	Findings	Normal/	Interstitial indistinct
metastases	thyroid, pancreas,	related to	↑ WBC, ↑ ESR.	pulmonary
	cervical, prostate, or	underlying		infiltrates (may be
	lung carcinoma.	malignancy.		reticulonodular)
				with lower lobe
				predominance
				Usually unilateral
				but may be bilateral.
				No consolidation or
				cavitation ± pleural
				effusions.

Drug-induced	Exposure to	Unremarkable.	Normal WBC ±	Bilateral coarse
	chemotherapeutic		↑ eosinophilia,	symmetrical patchy
	agents (e.g.,		normal/↑ ESR/	infiltrates/fibrosis ±
	BCNU, busulfan,		LFTs.	pleural effusions. Hilar
	methotrexate,		Eosinophils	adenopathy only
	cyclophosphamide,		in pleural	with drug-induced
	bleomycin) or		effusion.	pseudolymphoma
	other drugs (e.g.,			(secondary to
	nitrofurantoin,			dilantin). No
	sulfasalazine,			cavitation.
	amiodarone, opiates,
	cocaine).

Chapter 8. Chest X-Ray Atlas

463

CAVITARY INFILTRATES

(THICK-WALLED)

Infectious Causes Based on Speed of Cavitation

Speed of Cavitation	Causes

Very rapid cavitation (3 days)	S. aureus, P. aeruginosa
Rapid cavitation (5–7 days)	K. pneumoniae
Slow cavitation (> 7 days)	Pyogenic lung abscess, septic pulmonary emboli
Chronic cavitation	TB (reactivation), histoplasmosis (reactivation),
	sporotrichosis, melioidosis, nocardia, actinomycosis,
	Rhodococcus equi, amebic abscess, alveolar
	echinococcosis (hydatid cysts)

464	A n t i b i o t i c E s s e n t i a l s

Infectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

S. aureus	Fever, cough,	↓ breath	↑ WBC (left shift),	Multiple thick-
	dyspnea. Recent/	sounds ±	↓ pO2, ↑ A-a	walled cavitary
	concurrent	cyanosis.	gradient. Sputum	lesions super-
	influenza		positive for S.	imposed on normal
	pneumonia.		aureus. ↑ IgM	looking lung fields
			influenza titers.	or early minimal
				infiltrates of
				influenza.

P. aeruginosa	Nosocomial	Unremarkable.	↑ WBC (left shift).	Bilateral diffuse
	pneumonia		Respiratory	infiltrates with rapid
	usually on		secretions	cavitation
	ventilator. Nearly		culture ± for P.	(≤ 72 hours).
	always rapidly		aeruginosa. Blood
	fatal.		cultures positive
			for P. aeruginosa
			(hematogenous
			nosocomial
			pneumonia).

Klebsiella	Nosocomial	Fever, chills,	↑ WBC, ↓ platelets,	“Bulging fissure“
pneumoniae	pneumonia	signs of	↑ SGOT/SGPT	sign secondary to
	or history of	alcoholic	(2° to alcoholism).	expanded lobar
	alcoholism in	cirrhosis,	“Red currant jelly“	volume. Empyema
	patient with	signs of	sputum with	rather than pleural
	community-	consolidation	PMNs and plump	effusion. Usually
	acquired	over involved	gram-negative	cavitation in 5–7
	pneumonia.	lobe.	encapsulated bacilli.	days (thick walled).

Pyogenic	Recent aspiration.	Foul (putrid	↑ WBC, ↑ ESR.	Thick-walled cavity
lung abscess	Fevers, chills,	lung abscess)	Sputum	in portion of lung
	weight loss.	breath.	with normal	dependent during
	Swallowing		oropharyngeal	aspiration (usually
	disorder		anaerobic flora in	basilar segment
	secondary to CNS/		putrid lung abscess.	of lower lobes if
	GI disorder.			aspiration occurred
				supine). Cavitation
				occurs > 7 days.

Chapter 8. Chest X-Ray Atlas

465

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Septic	Usually IV drug	Fever > 102°F.	Blood cultures	Multiple peripheral
pulmonary	abuser with fever/	Tricuspid valve	positive for	nodules of varying
emboli	chills. Tricuspid	regurgitant	acute bacterial	size. Lower lobe
	regurgitation	murmur with	endocarditis	predominance.
	murmur or recent	cannon A	pathogens.	Cavitation > 7 days
	OB/GYN surgical	waves in neck.		characteristic of
	procedure.			septic pulmonary
				emboli.

TB	Fevers, night	± bilateral	Normal WBC,	Slowly progressive
(reactivation)	sweats, normal	apical dullness.	↑ platelets, ↑ ESR	bilateral infiltrates.
	appetite with		(≤ 70 mm/h).	No pleural effusion.
	weight loss, cough		Positive PPD. AFB	Usually in apical
	± hemoptysis.		in sputum smear/	segment of lower
			culture.	lobes or apical/
				posterior segments
				of upper lobes.
				Calcifications
				common.

Histoplas-	Fever, night	± E. nodosum;	Normal WBC,	Unilateral/
mosis	sweats, cough,	otherwise	normal/	bilateral multiple
(reactivation)	weight loss,	unremarkable.	↑ eosinophilia,	patchy infiltrates
	histoplasmosis		anemia, ↑ platelets,	with upper lobe
	exposure (river		PPD negative.	predilection.
	valleys of Central/		Immunodiffusion	Bilateral hilar
	Eastern United		test with positive	adenopathy
	States).		H precipitin band	uncommon.
			(diagnostic of	Calcifications
			active/chronic	common. No pleural
			histoplasmosis).	effusion. Chest
				x-ray resembles
				reactivation TB.

466	A n t i b i o t i c E s s e n t i a l s

Infectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Sporotrichosis	Fever, cough,	Only if	Normal WBC.	Unilateral > bilateral
	weight loss. ±	secondary	No eosinophilia.	upper lobe nodular
	hemoptysis.	to residual		densities. Thick
	Antecedent	of lympho-		or thin-walled
	lympho-	cutaneous		cavities. No hilar
	cutaneous	sporotrichosis,		adenopathy. No
	or skeletal	± E. nodosum.		pleural effusion.
	sporotrichosis, rare.

Melioidosis	Past travel to	Unremarkable.	↑ WBC (left shift),	Resembles
	Asia (usually		anemia, ↑ ESR, PPD	reactivation TB, but
	> 10 years).		negative. GNBs with	infiltrates nodular/
	Fever, cough,		bipolar “safety pin“	diffuse (septicemic)
	hemoptysis. ↑ risk		staining in sputum.	or cavitary (chronic)
	of reactivation/		Sputum/ blood	predominantly in
	dissemination with		cultures positive for	middle/lower lung
	DM, alcoholics,		B. (Pseudomonas)	fields. ± air fluid
	renal failure,		pseudomallei.	level. No pleural
	leukemias/			effusion.
	lymphomas,
	steroids, immuno
	suppressives. May
	occur in normal
	hosts.

Nocardia	Fevers, night	Unremarkable.	Normal/↑ WBC,	Dense large
	sweats, fatigue,		↑ ESR. Sputum with	infiltrates. May
	↓ cell-mediated		gram-positive AFB.	cavitate and mimic
	immunity (e.g., HIV,			TB, lymphoma,
	organ transplants,			or squamous cell
	PAP, immuno-			carcinoma. No
	suppressive			calcification ±
	therapy).			pleural effusion.

Actinomycosis	Recent dental	± chest wall	Normal/↑ WBC, ↑	Dense infiltrates
	work.	sinus tracts.	ESR. Sputum with	extending to
			Gram-positive	chest wall. No
			filamentous	hilar adenopathy.
			anaerobic bacilli.	Cavitation ± pleural
				effusion rare.

Chapter 8. Chest X-Ray Atlas

467

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Rhodococcus	Insidious onset	Unremarkable.	Normal/↑ WBC.	Segmental infiltrate
equi	of fever, dyspnea,		Sputum/pleural	with upper lobe
	chest pain, ±		fluid with	predominance ±
	hemoptysis.		gram-positive	cavitation. Air-fluid
	Immuno-		pleomorphic weakly	levels and pleural
	suppressed		acid-fast bacilli.	effusion common.
	patients with ↓		Sputum, pleural
	cell-mediated		fluid, blood cultures
	immunity or		positive for R. equi.
	exposure to cattle,
	horses, pigs.

Amebic cysts	Hepatic amebic	± hepato	Normal WBC and	Well-circumscribed
	abscess. Remote	megaly.	ESR. ↑ E. histolytica	cavitary lesions
	history of usually		HI titers.	adjacent to right
	mild amebic			diaphragm. ±
	dysentery.			calcifications.
				Sympathetic pleural
				effusion above
				hepatic amebic
				abscess.

Alveolar	Symptoms	Hepatomegaly	Normal/↑ WBC,	RLL usual
echinoco-	related to cyst	common.	no eosinophilia, ↑	location (hepatic
ccosis (hydatid	size/ location: 1/3		alkaline phosphate/	cysts penetrate
cysts)	asymptomatic; 2/3		SGPT with hepatic	diaphragm into
	with fever, malaise,		cysts. Abdominal	RLL). Nodules
	chest pain ±		ultrasound/CT with	are 70% solitary,
	hemoptysis. RUQ		calcified hepatic	30% multiple.
	abdominal pain		irregularly shaped	Pleural effusion
	may occur.		cysts (“Swiss	rare. Endocyst
			cheese“ calcification	membrane on
			characteristic).	surface of cyst fluid
			↑ E. multilocularis	(“water lilly“ sign) is
			IHA titers.	characteristic.

468	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Wegener’s	Most common	Findings of	↑ WBC, anemia,	Bilateral asymmetrical
granulom-	in middle-	chronic sinusitis,	↑ platelets,	nodular infiltrates of
atosis	aged adults.	bloody nasal	↑ ESR, ↑ RF,	varying size with irregular
	Cough, fever,	discharge.	negative ANA,	margins. Cavitation
	fatigue.		proteinuria,	common. Inner lining
			hematuria.	of cavities irregular. Air-
			Positive cANCA.	fluid levels rare. ± pleural
				effusions. No calcifications.

Squamous	Long-term	Clubbing,	↑ Ca++	Unilateral perihilar mass
cell	smoking	hypertrophic	(without bone	lesion. Cavitation common.
carcinoma	history.	pulmonary	metastases).	No pleural effusion.
		osteoarthropathy
		± findings 2° to
		superior vena
		caval syndrome
		and CNS/bone
		metastases.

Lymphoma	Fever, ↓	Adenopathy ±	Normal WBC,	Unilateral or asymmetrical
	appetite with	splenomegaly.	↑ basophils,	bilateral hilar adenopathy.
	weight loss,		↑ eosinophilia, ↓	Lung infiltrate may
	night sweats,		lymphocytes, ↑	appear contiguous with
	fatigue.		platelets,	hilar adenopathy. No
			↑ ESR ↑ alkaline	clear channel between
			phosphatase,	mediastinum and hilar
			↑ 1, 2 globulins	nodes. Small pleural
			on SPEP.	effusions rare.

Chapter 8. Chest X-Ray Atlas

469

Noninfectious Causes (cont’d)

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Metastatic	History	Findings related	Secondary	Nodular lesions that vary in
carcinoma	of breast,	to underlying	to effects	size. Metastatic lesions are
	thyroid, renal	malignancy and,	of primary	usually well-circumscribed
	cell, colon,	when present,	neoplasm,	with lower lobe
	pancreatic	to bone, hepatic,	metastases,	predominance. Usually
	cancer or	CNS metastases.	paraneoplastic	no bronchial obstruction
	osteogenic		syndrome.	(obstruction suggests
	sarcoma.			colon, renal, or melanoma
				metastases). Usually no
				cavitation (except for
				squamous cell metastases).
				Calcification usually
				suggests osteosarcoma
				(rarely adenocarcinoma).
				Pleural effusion rare (except
				for breast cancer).

Rheumatoid	Usually	Findings	Normal WBC,	Lung nodules are round
nodules	in severe	secondary to	↑ ESR, ↑ ANA,	and well-circumscribed,
	rheumatoid	RA. Rheumatoid	↑ RF (high titer).	predominantly in lower
	arthritis (RA);	nodules on	Pleural fluid	lobes and typically
	± history of	exterior surfaces	with ↓ glucose.	superimposed on
	silicosis.	of arms.		interstitial lung disease
				(“rheumatoid lung“).
				Cavitation is common.
				± pulmonary fibrosis,
				pleural effusion. Silicosis +
				RA nodules = Caplan’s
				syndrome.

470	A n t i b i o t i c E s s e n t i a l s

CAVITARY INFILTRATES

(THIN-WALLED)

Infectious Causes

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Atypical TB	Often occurs in	Unremarkable.	Normal WBC,	Multiple cavitary
	setting of previous		↑ ESR. Weakly	lesions ±calcifications
	lung disease.		positive	usually involving both
			PPD. Positive	lungs. Resembles
			sputum AFB/	reactivation TB except
			culture.	that cavities are thin-
				walled. No pleural
				effusion.

Coccidiomycosis	Previous exposure	± E. nodosum.	Normal WBC.	Thick/thin walled
(reactivation)	in endemic		Eosinophilia	cavities (< 3 cm)
	coccidiomycosis		acutely but	usually in anterior
	areas (e.g.,		not in chronic	segments of lower
	Southwest USA).		phase, and	lobes ± calcifications/
	Asymptomatic.		eosinophils in	bilateral hilar
			pleural fluid. CF	adenopathy. Air-fluid
			IgG titer ≥ 1:32	levels rare unless
			indicates active	secondarily infected.
			disease.	Pleural effusion rare.

Chapter 8. Chest X-Ray Atlas

471

Infectious Causes (cont’d)

	Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Paragonimiasis	Ingestion of	Wheezing,	↑ WBC,	Cavitary patchy
	fresh-water crabs/	± urticaria	eosinophilia.	or well-defined
	crayfish. Acute	(acutely).	Eosinophils in	infiltrates
	symptoms (< 6		pleural fluid.	predominantly in
	months): fevers,		Sputum with	mid-lung fields.
	abdominal pain,		Charot-Leyden	Hydropneumothorax
	diarrhea followed		crystals.	common.
	by episodes of		Sputum/feces	Calcifications and
	pleuritic chest		with	pleural effusion
	pain. Chronic		operculated	common.
	symptoms		P. Westermani
	(> 6 months):		eggs.
	fevers, night
	sweats, cough
	± hemoptysis.
	Asymptomatic in
	some.

Sporotrichosis	Fever, cough,	Only if	Normal WBC.	Unilateral > bilateral
	weight loss. ±	secondary	No eosinophilia.	upper lobe nodular
	hemoptysis.	to residual		densities. Thick or
	Antecedent	of lympho-		thin-walled cavities.
	lymphocutaneous	cutaneous		No hilar adenopathy.
	or skeletal	sporotrichosis, ±		No pleural effusion.
	sporotrichosis,	E. nodosum.
	rare.

Pneumatoceles	Common in S.	Unremarkable	↑ WBC (left	Multiple thin-walled
	aureus pneumonia	unless	shift), ↓ pO2	cavities in areas of
	in children. Fever,	pneumatocele	(secondary to	S. aureus pneumonia.
	cough, dyspnea.	ruptures,	influenza).	Common in children;
	± antecedent	then signs of		rare in adults.
	influenza.	pneumothorax.

472	A n t i b i o t i c E s s e n t i a l s

Noninfectious Causes

Features (may have some, none, or all)

Causes	History	Physical	Laboratory	Chest X-Ray

Emphysema	Long history	Asthenic	Normal WBC,	↓ lung markings (“vanishing
(blebs/cyst)	of smoking.	“pink puffers.“	↓ pO2.	lung“) ± blebs. Hyperlucent
	Rupture of	Barrel chest.		lungs with upper lobe
	apical bleb	Diaphragmatic		predominance. Flattened
	common	excursions		diaphragms, vertically
	in males	< 2 cm.		elongated cardiac
	> 30 years.			silhouette, ↑ retrocardiac
	Pneumonia			and retrosternal airspaces.
	rare in severe			No infiltrates or pleural
	emphysema			effusions. (In upper lobe
	(vs. chronic			emphysema, no vascular
	bronchitis) but			redistribution to upper lobes
	may occur early			with CHF).
	in unaffected
	areas of lung.

Bronchogenic	Congenital	Unremarkable	Normal WBC/	Circumscribed cystic
cyst	anomaly.	unless	ESR.	lesion originates in lung
	Usually	secondarily		but appears high in
	asymptomatic.	infected, then		mediastinum. If filled with
	Cough if	signs 2° to		fluid, appears as solitary
	symptomatic.	mediastinal		tumor. If near the trachea,
		abscess.		may rupture into bronchus/
				trachea and cyst may
				contain air. If communicates
				openly with bronchus,
				appears as thin-walled
				cavitary nodule. If infected,
				presents as mediastinal
				abscess.

Cystic	Recurrent	Unremarkable	↑ WBC, normal	Bilateral large cystic
bronchiectasis	pulmonary	unless	ESR.	lucencies at lung bases.
	infections with	dextrocardia		Upper lobes relatively
	purulent	with sinusitis		spared (unless secondary
	sputum ±	(Kartagener’s		chronic aspiration).
	hemoptysis.	syndrome).		Thickened bronchial
				markings at bases.
				Bronchiectasis of cystic
				fibrosis predominantly
				involves upper lobes.

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