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 of the findings.


Case A:
     This is a 16-month old male with coughing, 
wheezing, and tachypnea.

View Case A.





Interpretation of Case A
     No acute infiltrates are seen.  There is a faint 
vertical lucency paralleling the right mediastinal border 
see only on the PA view.  No other vertical air densities 
are seen.  This may be an artifact or this patient may 
have a small pneumothorax or a pneumomediastinum.  
A pneumomediastinum usually has other vertical air 
densities over the upper mediastinum on the PA view 
and over the thymic space on the lateral view.  In this 
case, the thymic space is normal.
     Impression:  Right mediastinal lucency.  This is 
mostly likely an artifact or possibly,  a small right 
pneumothorax or pneumomediastinum.


Case B:
     This is a 9-month old male with fever and coughing.

View Case B.





Interpretation of Case B
     This film is dark.  Turn down the room lights and 
adjust the brightness and contrast on your screen.  
There is an area of density best seen on the lateral 
view posteriorly just above the diaphragm over the 
inferior vertebral body.  This represents consolidation at 
the medial aspect of the left lung base posteriorly.  On 
the lateral view, these vertebral bodies should 
progressively darken (become blacker) as you proceed 
inferiorly (T1 to T12).  If one the vertebral bodies 
appears whiter than it should be, this is often due to an 
overlying soft tissue density such as an infiltrate or 
consolidation. 
     Impression:  Subsegmental consolidation of the 
posterior segment of the left lower lobe.


Case C:
     This is a 2-month old female who is wheezing.

View Case C.





Interpretation of Case C
     The diaphragms are flattened indicating bilateral 
hyperaeration.  The lateral view demonstrates this best.  
Both diaphragms have lost the usual dome appearance.  
They are both flattened obliquely.  Additionally, the 
lateral view shows the increased AP diameter.  In small 
children, hyperaeration (flattened diaphragms) are best 
demonstrated on the lateral view as seen here.
     There may be slight accentuation of the central lung 
markings suggesting a viral pneumonia.
     Impression:  Hyperaeration with accentuated central 
lung markings.


Case D:
     This is a 15-month old male with fever and 
coughing.

View Case D.






Interpretation of Case D
     There is a density in the right upper lobe.  This is not 
due to the scapula since the other side does not have 
this appearance.  This is a patchy area of consolidation 
in the posterior portion of the right upper lobe.
     Impression:  Partial right upper lobe consolidation.


Case E:
     This is a 6-week old female presenting with fever 
and cold symptoms.  Her temperature is 39 degrees 
rectally.  She is feeding well.
     Exam  VS T39.1 (rectal), P125, R45, BP 75/35, 
oxygen saturation 98% in room air.  She is alert and 
active.  She is not toxic and not irritable.  AF flat and 
soft.  TM's normal.  Oral clear.  Neck supple.  Heart 
regular without murmurs.  Lungs are probably clear, but 
there may be some wheezing.  Abdomen benign.

View Case E.






Interpretation of Case E
     The lungs are hyperaerated.  The diaphragms are 
flattened (most notably, on the lateral view).  There is a 
density in the right upper lobe seen best on the PA 
view.  The scapula can be visualized distinctly from this 
density.  This is an area of consolidation or atelectasis 
in the posterior segment of the right upper lobe.  This 
density is also evident on the lateral view in the superior 
posterior region.
     Impression:  Hyperaeration of the lungs with an area 
of consolidation or atelectasis in the posterior segment 
of the right upper lobe.


Case F:
     This is a 3-year old male with fever and coughing.

View Case F






Interpretation of Case F
     There is a patchy area of consolidation in the 
posterior portion of the left lower lobe.  The lateral view 
best demonstrates this as a density over the inferior 
vertebral bodies.  As stated earlier, the appearance of 
the vertebral bodies should darken as one proceeds 
inferiorly.  Note that the two most inferior vertebral 
bodies above the diaphragm are whiter than the 
vertebral bodies above them.  This is due to an 
overlying consolidation that is clearly outlined when 
examining the radiograph carefully.  This density is 
located behind the heart making it difficult to see on the 
PA view.  However, an increased streakiness (density) 
is seen over the left inferior lateral heart border.
     Impression:  Segmental area of consolidation in the 
posterior portion of the left lower lobe.


Case G:
     This is a 3-year old male with fever and coughing.  
He is tachypneic.  Crackles are heard on the left.  No 
wheezing is heard, but he has a bronchospastic cough.  
There is no past history of asthma.

View Case G.






Interpretation of Case G
     The central markings are accentuated.  The lungs 
are otherwise clear.
     Impression:  Accentuated lung markings.


Case H:
     This is a 3-year old male with a history of a 
fever and coughing for one week.  Rales are heard on 
the right.

View Case H.






Interpretation of Case H
     The central markings are definitely accentuated.  
There is an infiltrate in the right middle lobe. 
     Impression:  Bilateral central and right middle lobe 
infiltrates.


Case I:
     This is a 14-month old female with a past history of 
severe prematurity and chronic lung disease.  She 
now has fever, coughing, and wheezing.

View Case I.






Interpretation of Case I
     The pulmonary outflow tract is prominent.  The 
central markings are accentuated and fluffy, more so on 
the right.  This is evident on the PA view.  However, the 
lateral view also demonstrates increased markings and 
fluffiness around the hilum.  These findings are 
consistent with chronic lung disease and possibly 
suggestive of pulmonary hypertension.
     Impression:  Accentuation of the central markings.  
Chronic lung disease (bronchopulmonary dysplasia) 
and possible pulmonary hypertension.


Case J:
     This is an 14-month old male with a history of 
coughing and fever.

View Case J.






Interpretation of Case J
     The PA view demonstrates a density in the left 
upper lobe.  The lateral view demonstrates a triangular 
density in the upper lung and a flat density positioned 
obliquely over the heart.  The upper density is an area 
of consolidation in the posterior apical segment of the 
left upper lobe.  The lower density over the heart is a 
consolidation of the lingula.  Note that the PA view does 
not demonstrate any densities on the right in the area of 
the right middle lobe.  An infiltrate in the lingula usually 
obscures the left heart border (not so obvious in this 
case).
     Impression:  Left upper lobe and lingula 
consolidation.


Case K:
     This is a 4-month old with respiratory distress and 
diminished breath sounds on the right.

View Case K.






Interpretation of Case K
     PA inspiratory and expiratory views are shown here.  
The inspiratory view demonstrates hyperexpansion of 
the right hemithorax.  The right hemithorax is blacker 
than the left.  The right hemithorax is also bigger than it 
should be.  Lung markings are evident throughout both 
lungs making this incompatible with a pneumothorax.  
The expiratory view shows satisfactory emptying of the 
left lung, but persistent hyperexpansion of the right 
lung.
     The diagnosis of foreign body is considered, but the 
typical age group for a bronchial foreign body is 2 years 
and above.  This child's past history is significant for 
complaints of abnormal breathing in the past.
     Closer examination of the radiographs on the right 
show a density in the upper medial hemithorax (small 
density compressed against the upper mediastinum).  
This is probably a compressed right upper lobe.  
     Impression:  Hyperexpansion of the right middle and 
right lower lobes raising the possibility of an obstruction 
in the intermediate right bronchus.
     This child is ultimately found to have a congenital 
lobar emphysema of the right middle lobe.  The topic of 
lobar emphysema is discussed in more detail in Case 9 
of Volume 1, Respiratory Distress - That's a Tension 
Pneumothorax Isn't It?


Case L:
     This is a 4-month old female with a history of fever 
and coughing.

View Case L.






Interpretation of Case L
     The PA view looks fairly normal except for blurring 
of the left medial diaphragm.  The lateral view 
demonstrates an infiltrate superimposed over the 
inferior aspect of the spine just above the diaphragm.  
The vertebral bodies inferiorly should be blacker than 
the vertebral bodies above them.  In this case, the 
inferior vertebral bodies are whiter indicating the 
presence of an overlying soft tissue density.  It is hard 
to appreciate any infiltrate on the PA view since it is 
behind the heart on the left. 
     Impression:  Small infiltrate in the posterior portion 
of the left lower lobe.


Case M:
     This is a 6-week old female with a history of fever 
and cold symptoms.

View Case M.






Interpretation of Case M
     There is a faint density in the right upper lobe on the 
PA view.  The lateral view also demonstrates this 
density in the upper lung posteriorly.  The diaphragms 
are flattened indicating hyperaeration.
     Note the spherical density overlying the middle 
portion of the right clavicle.  This is callus formation of a 
healing right clavicle fracture.  Healing clavicle fractures 
in this age group are usually due to fractures occurring 
during birth.  While most of these are diagnosed on 
routine examination at birth, some of these are not.  
Such a finding on a chest radiograph may be the first 
indication of a clavicle fracture.  This problem is benign 
and does not require any special care at this point.  
Consider the possibility of child abuse if the history or 
the appearance of the fracture does not suggest that it 
was caused by the birthing process.
     Impression:  Hyperaeration of the lungs with an area 
of consolidation or atelectasis in the posterior segment 
of the right upper lobe.   Healing right clavicle fracture.


Case N:
     This is a 17-month old male with a history of fever, 
coughing, and respiratory distress.

View Case N.






Interpretation of Case N
     There is an obvious consolidation of the right upper 
lobe.  Although both costophrenic angles are sharp, 
note the abnormal contour of the right hemidiaphragm.      
     The diaphragm should have a domed appearance 
(normal) or a flattened appearance (hyperexpanded 
lungs).  But the right hemidiaphragm here has an 
unusual contour where it is flat medially, then it sharply 
dips downward laterally.  The diaphragms should 
normally be highest in the middle (domed appearance) 
or highest medially (flattened appearance).
     Case 4 of Volume 2 describes a case of pleural 
effusions.  The diaphragms in this case also had 
unusual contours where the lateral portions of the 
diaphragms were higher than the medial or center 
portions of the diaphragms.  This finding is associated 
with the presence of a pleural effusion even if the 
costophrenic angles are sharp.
     This patient's PA radiograph demonstrates a 
substantial consolidation of the right lung with an 
abnormal diaphragm contour.  Although the lateral 
aspect of the diaphragm is not truly the highest point of 
the diaphragm, this is still suspicious for a pleural 
effusion.  Subsequent radiographs of this patient's 
lungs demonstrated the presence of a pleural effusion.
     Looking back at the lateral view, the posterior 
costophrenic angle may be blunted suggesting a pleural 
effusion, however, this is where the film is cut off, thus, 
this appearance may be an artifact.
 

Case O:
     This is a 2-month old male with fever, noisy 
breathing, and tachypnea.  His breath sounds are 
slightly coarse.

View Case O.






Interpretation of Case O
     The PA view demonstrates moderate cardiomegaly 
and accentuation of the central markings.  These 
findings are most consistent with early congestive heart 
failure rather than a viral pneumonia.  This PA view is 
slightly rotated making this radiograph more difficult to 
interpret.  The prominent right side of the heart, was 
initially felt to be due to the rotation.  However, it is too 
large to be due to rotation alone.
     Impression:  Early congestive heart failure.
     An echocardiogram confirmed the presence of 
congestive heart failure due to congenital heart disease.  
This case is discussed in more detail in Case 3 of 
Volume 4, Tachypnea in a 2-Month Old.


Case P:
     This is a 3-year old male with frequent colds who 
now presents with fever and coughing.

View Case P.





Interpretation of Case P        
     The PA view shows both lower lung fields to be 
denser than the upper lung fields.  This is more evident 
on the left than on the right.  The apex of the heart is 
displaced outward suggesting the possibility of early 
congestive heart failure.
     However, in this instance, the findings above are all 
due to a slightly suboptimal inspiratory effort.  Because 
of the poor inspiration, the central markings are 
crowded.  The diaphragm is at the level of the 9th rib.  
Ideally, the 9th posterior rib should be above the 
diaphragm.
     Impression:  No definite acute cardiopulmonary 
disease.  Borderline suboptimal inspiration.