Test Your Skill In Reading Pediatric Chest Radiographs
Radiology Cases in Pediatric Emergency Medicine
Volume 3, Case 20
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
     Test your skill in reading these 16 pediatric chest 
radiographs.  Many of these have subtle findings.  
Unfortunately, subtle findings become even less 
obvious when they are displayed on a computer 
monitor.  They are reproduced here as best as 
possible.  You may need to darken the room lights and 
adjust the contrast and brightness on your monitor to 
appreciate some findings.

Case A:
     This is a 15-month old male with fever, coughing, 
and tachypnea.

View Case A.

Interpretation of Case A
     Bilateral central pulmonary infiltrates, but most 
marked in the right middle and left lower lobes.  The
left lower lobe infiltrate is best seen on the lateral
view inferiorly over the spine.  The lungs are 
     Impression:  Right middle and left lower lobe 

Case B:
     This is a 3 year old female whose parents do not 
speak English well.  Her chief complaint is coughing 
and difficulty breathing.  There is mild bilateral stridor on 
exam.  Her cough sounds slightly bronchospastic, but 
not barking in nature.

View Case B.

Interpretation of Case B
     No infiltrates are noted.  The right side is more 
lucent (darker) compared to the left.  This is subtle and 
may be difficult to appreciate unless you step back and 
view the CXR from a distance.  The right 
hemidiaphragm is slightly higher than the left 
hemidiaphragm, however, it should be higher than this.  
Both these findings suggest right sided hyperexpansion.  
More clinical history through a translator indicated that 
she was jumping on a bed while eating some food 
(thought to be meat), when she began choking.  Since 
that time, she has experienced respiratory difficulty.  
Further radiographs revealed bilateral air trapping.  
Bronchoscopy revealed bilateral bronchial peanut 
fragment foreign bodies.
     Impression:  Right sided hyperexpansion and air 
trapping.  Possible bronchial foreign body.

Case C:
     This is a two week old male infant who arrived in the 
E.D. with a history of noisy breathing and worsening 
respiratory distress.  VS T36.7, P160, R60, BP 100/70.  
His color is dusky.  His oxygen saturation is 86% in 
room air.  Oxygen is applied and his color improves.  
His oxygen saturation is now 96%.  He has diminished 
breath sounds bilaterally.  There are moderately severe 

View Case C

Interpretation of Case C
     There is hyperlucency of the left chest with a 
mediastinal and cardiac shift to the right.  Although this 
may look like a tension pneumothorax, realize that such 
a large tension pneumothorax would generally be 
associated with hypotension, bradycardia, and 
persistent hypoxia (despite supplemental oxygen).  
Since this infant appears to have good cardiovascular 
function and his oxygenation improved with 
supplemental oxygen, one should not immediately jump 
to evacuating the left chest since he is currently stable.
     After carefully reassessing the situation and 
reexamining the CXR, it is evident that lung markings 
are present in the left chest.  This represents a 
hyperexpanded lobe.  The hyperexpansion is so severe 
that it compresses the remaining left lung and pushes 
the heart and mediastinum to the right, compressing the 
right lung as well.
     Impression:  Left upper lobe hyperexpansion with 
mediastinal shift.  Congenital lobar emphysema.  This 
case is discussed in more detail in Volume 1, Case 9.

Case D:
     This is a 3-month old female with fever and 

View Case D.

Interpretation of Case D
     This is a dark film.  It is best read using a hot light.  
To maximize visibility on the computer monitor, turn off 
the room lights and adjust the contrast and brightness 
controls on your monitor to maximize image quality.
     There is a faintly visible infiltrate in the right upper 
lobe.  Subtle findings may be more difficult to 
appreciate on dark films.
     Impression:  Right upper lobe infiltrate.

Case E:
     This is a two month old male with a history of a VSD 
(taking digoxin) arriving in the E.D. for a possible 
seizure.  His parents witnessed an episode of body 
stiffness, jerking of all extremities, and upward rolling of 
his eyes lasting one minute.  An ambulance brought 
him to the E.D.
     His exam was significant for a harsh grade III/VI 
systolic murmur.  His lungs were clear.  He was alert 
and active, and no neurologic abnormalities could be 
detected.  He promptly had another generalized seizure 
in the ED which lasted five minutes.  An IV could not be 
started during the seizure.  After the seizure, he was 
not drowsy.  An IV was started, and he was given IV 
lorazepam and phenobarbital.

View Case E.

Interpretation of Case E
     There is cardiomegaly with slightly prominent 
pulmonary vascularity suggesting a left to right shunt.  
An unexpected finding was the absence of a thymic 
shadow that one would expect to see in a 2-month old.  
A prominent thymus is usually visible in the upper 
mediastinum on the AP or PA view.  On the lateral 
view, the space anterior and superior to the heart is 
usually occupied by the thymus in this age group.  
However, in this child, the thymic space is occupied by 
lung tissue.
     His laboratory studies were significant for 
hypocalcemia.  Although his clinical presentation 
resembled a classic seizure, in retrospect, the 
hypocalcemia suggests that these episodes were 
symptomatic tetany.
     Impression:  Cardiomegaly and absence of the 
thymic shadow.  In conjunction with the VSD and 
hypocalcemia, this is most consistent with DiGeorge 
syndrome (thymic and hypoparathyroid aplasia or 
hypoplasia).  This case is discussed in more detail in 
Volume 2, Case 2.

Case F:
     This is a 16 year old male presenting to the 
emergency department with moderately severe acute 
wheezing.  His oxygen saturation is 95% in room air.  
He is noted to be wheezing.  He is given an albuterol 
aerosol and he is noted to improve, but his degree of 
aeration is still somewhat poor.  He complains of mild 
chest pain.

View Case F.

Interpretation of Case F
     Both lungs are hyperaerated.  There are vertical air 
densities seen in the upper mediastinum extending up 
into the soft tissues of the neck.  This is evidence of air 
dissecting against the left border of the cardiac 
silhouette.  There is no evidence of pneumothorax.
     Impression:  Pneumomediastinum.
     In a pneumomediastinum, the lateral view will often 
show air dissecting along the trachea or free air may be 
visible in the space anterior to the heart in the thymic 
region.  In this case, free air in the thymic region is 
visible, but it may be difficult to see it on your computer 
monitor.  There are vertical oblique air densities in the 
thymic space anterior and superior to the heart on the 
lateral view.  Darken the room and adjust the contrast 
and brightness on your monitor to see it best.

Case G:
     This is a 10 year old male who came to the E.D. with 
a history of coughing and fever.  Poor breath sounds 
were noted on the left.

View Case G.

Interpretation of Case G
     The left lung is consolidated.  This atelectasis 
results in a mediastinal shift to the left.  There are air 
bronchograms evident over the left lung.  On the 
original film, there is a suggestion of a 1.5cm cylindrical 
foreign body in the left mainstem bronchus.  Further 
history revealed that he had "swallowed" a plastic bullet 
several days ago.
     Impression:  Consolidation of the entire left lung with 
the suggestion of a foreign body in the left mainstem 

Case H:
     This is an 11-month old female with a history of a 
previous pneumonia who now presents with fever and 
coughing.  Mild wheezing and rales are noted on 

View Case H.

Interpretation of Case H
     There are small interstitial central pulmonary 
     Impression:  Small interstitial central pulmonary 
infiltrates most consistent with a viral pneumonia.

Case I:
     This is a 6-week old male infant.  His parents 
brought him to the E.D. because of coughing and 
congestion.  He had a 20 minute episode of frequent 
coughing, but now seems to be better.  He is feeding 
well.  There is no history of fever or cyanosis.  His vital 
signs are normal.  Oxygen saturation is 100% in room 
air.  Auscultation is clear.

View Case I.

Interpretation of Case I
     The upper mediastinum shows the usual prominent 
thymus for this age.  The thymic shadow is larger on 
the infant's right than on his left.  There is a density in 
the right upper lobe, but it is obscured by the thymus.  
Part of this density appears to be from the scapula, but 
on close inspection, there are densities suggesting 
infiltrates aside from the thymus and the scapula in the 
right upper lobe.
     Impression:  Right upper lobe infiltrate or partial 

Case J:
     This is an 18-month old female with a history of 
prematurity and mild bronchopulmonary dysplasia.  She 
arrives in the emergency department with a history of 
fever, coughing, and difficulty breathing.  Coarse breath 
sounds and mild wheezing are noted on auscultation.

View Case J.

Interpretation of Case J
     There is a small area of atelectasis in the right 
middle lobe.  This is best seen on the lateral view as an 
oblique flattened wedge shaped density over the heart.  
Instead of the normal triangular shape of the right 
middle lobe, it appears to be flat and compressed 
indicating atelectasis.
     Impression:  Right middle lobe atelectasis.

Case K:
     This is a 5-week old infant with a history of fever and 
coughing.  He arrives in the emergency department with 
severe respratory distress.  His initial CXR shows a 
small pneumonia.  He is thought to have a staph aureus 
pneumonia because of his severe condition.  He 
requires mechanical ventilation in an intensive care unit.  
During his second day of hospitalization, he suddenly 
becomes severely cyanotic, bradycardic, and 
hypotensive.  He has good breath sounds bilaterally.  
This portable CXR (AP only) is obtained.

View Case K.

Interpretation of Case K
     There is a lucency visible surrounding the heart; 
representing air dissecting into the pericardium.
     Impression:  Pneumopericardium
     Pneumopericardium is usually a serious emergency 
since it results in sudden cardiac tamponade.  
Immediate pericardiocentesis is required.  This is a 
highly complication prone procedure since it may 
lacerate the heart and even if it temporarily relieves the 
tamponade, more air will continue to accumulate in the 
pericardial space resulting in recurrent tamponade.  
Because of reaccumulation of air, inserting a plastic 
catheter into the pericardium using an IV catheter over 
needle or the Seldinger technique, may be more 
effective at preventing reaccumulation of air and 
tamponade.  If a surgeon is immediately available, a 
pericardial window procedure may be more efficacious 
immediately following pericardiocentesis.

Case L:
     This is an 11-year old female with a history of fever 
and coughing for 5 days.  VS T39.1 (oral), P122, R 20, 
BP 107/76.  Oxygen saturation 99% in room air.  
Auscultation is significant for moist rhonchi in the left 

View Case L.

Interpretation of Case L
     There is a patchy infiltrate at the left lung base.  This 
is seen on the lateral view obliquely over the heart and 
on the PA view as haziness in the left lower lung.  The 
prominence of the right perihilar region is probably due 
to rotation.  Note the asymmetry of the spinal column 
and the ribs.  This rotation exposes more of the right 
hilum in the radiograph, making it appear more 
     Impression:  Patchy area of consolidation at the left 
lung base.

Case M:
     This is a 12-year old female complaining of a 
headache and productive cough.  Onset of fever last 
night to 39 degrees.  Rales are noted in the left base.

View Case M.

Interpretation of Case M
     There are infiltrates in the right middle and left lower 
lobes.  The right middle lobe infiltrate is blurring the 
right heart border.  It can also be seen on the lateral 
view as streakiness over the heart.  The left lower lobe 
infiltrate is best seen on the lateral view posteriorly on 
the diaphragm. It can also be seen on the PA view as 
haziness in the lower lung on the left.  The infiltrate in 
the right middle lobe was noted two years ago on a 
previous radiograph, and the possibility of a chronic 
infiltrate was raised.
     Impression:  Right middle and left lower lobe 

Case N:
     This is a 9-year old male with a history of fever, 
headache, nausea, and coughing.

View Case N.

Interpretation of Case N
     There is a circular density in the right lung.  This is 
the superior segment of the right lower lobe.  Although 
this has the appearance of a mass, it is most likely an 
infectious process.
     Impression:  Spherical consolidation in the right 
lower lobe (round pneumonia).

Case O:
     This is a 20-year old male who arrives in the E.D. 
complaining of difficulty breathing.  He also describes 
some mild chest pain.  He is a poor historian, but does 
admit to smoking crack cocaine earlier in the day.  
Auscultation reveals a "friction rub" that occurs in 
synchrony with his heart rate.  His pulses and perfusion 
are good.

View Case O.

Interpretation of Case O
     On the PA film, air is seen dissecting along the 
superior mediastinum bilaterally.  These vertical air 
densities extend up into the soft tissues outside the 
pleural cavity.  There is also air superimposed over the 
inferior aspect of the aortic arch.  The lateral view 
shows air densities demarcating the thymus.  You may 
have to darken the room and adjust the contrast and 
brightness controls on your monitor to appreciate this.  
The lateral view also shows vertical air densities 
outlining the trachea.
     Impression:  Pneumomediastinum.
     Pneumomediastinum is commonly associated with 
substance abuse and other activities that involve a 
valsalva maneuver.  The "friction rub" that was 
auscultated was not really a friction rub.  This grating 
sound called Hamman's Sign is associated with 
pneumomediastinum.  This case is discussed in more 
detail in Volume 1, Case 7.

Case P:
     This is a 17-month old female with a history of fever 
and coughing.  She is crying on exam making 
auscultation difficult.  Oxygen saturation is 98% in room 

View Case P.

Interpretation of Case P        
     There is a small subtle infiltrate in the left 
costophrenic angle.  This is best seen on the PA view 
as an increased density where the ribs cross each other 
in the left lower lung near the costophrenic angle.
     Impression:  Small infiltrate in the left costophrenic 

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Web Page Author:
Loren Yamamoto, MD, MPH
Associate Professor of Pediatrics
University of Hawaii John A. Burns School of Medicine