Radiology , Diagnosis radiology, Chest radiology, Pattern and differential diagnoses of Pleural effusion, Chest X ray, CT

1. CHEST RADIOLOGY
PATTERNS AND DIFFERENTIAL
DIAGNOSES
Chest
Pleural effusion
Maw Maw

2. CAUSES
• Congestive hear failure
• Thromboembolic disease
• Infection
• Neoplasm
• Collagen vascular disease
• Trauma
• Abdominal disease
• Diffuse pulmonary disease
• Drug reaction
• Others
• Post MI
• Radiation therapy
• Post pneumonectomy space
empyema
• Coagulation defect
• Empyema from neck and
retrophayngeal abscess
• idiopathic

3. FEATURES
• Blunting of costophrenic angle
• Apparent elevation of diaphragm
• Peripheral homogeneous opacity with a line that parallels the lateral
chest wall
• Opacification in interlobar fissure
• Complete opacification of entire hemithorax with shift of mediastinum

4. DECUBITUS EXAMINATION
• Show change in positon of opacity
• Confirm free flow effusion
• No change in position – Loculated pleural effusion, pleural scarring,
pleural mass
• Loculated pleural effusion –difficult to confirm – USG and CT

6. PLEURAL EFFUSION WITH LARGE
CARDIAC SILHOUETTE
• Congestive heart failure- specific combination of cardiac and vascular
findings
• Cardiomegaly+prominence of upper lobe vessles+constriction of lower
lobe vessels+prominent hilar vessels
• Interstitial edema( fine recticular opacities, interlobular septal thickening,
perihilar haze and peribronchial thickening)
• Evidence of alveolar edema( acinar nodules, confluent, ill defined
opacities with perihilar distribution and air bronchogram)
• Effusion in congestive heart failure – unilateral ( right ) and bilateral

7. CONGESTIVE HEART FAILURE
• Cardiomegay+ pleural effusion
• absence of pulmonary vascular congestion and sign of pulmonary
interstitial or alveolar edema
• Consistent with congestive heart failure
• Because interstitial or alveolar edema –resolve rapidly response to
diuretics

8. CHRONIC RENAL FAILURE
• Pulmonary edema
• Associated pleural effusion
• Associated congestive heart failure due to secondary to fluid overload

9. PULMONARY EMBOLISM
• Pleural effusion
• Right sided heart enlargement
• Effusion atypical ( left side) –if increased when pulmonary edema is clear-
possible embolism
• Chest pain
• Hemoptysis
• Sudden shortness of breath
• Pleural fiction rub
• PO2 decreased and thrombophlebitis

10. METASTATIC OR INFLAMMATORY
DISEASE
• Cardiac enlargement due to pericardial effusion with pleural effusion
• History of malignancy – metastatic pleural and pericardial effusion
• History of fever – pericarditis or myocarditis
• Pleural and pericardial effusion – common in SLE

11. A large homogeneous opacity in the right lateral
chest has a sharp line separating it from the
partially aerated lung. This is the result of a large
pleural effusion caused by metastatic disease

12. A, The blunting of both costophrenic angles with apparent elevation of the left diaphragm provides the clue to
suspect bilateral pleural effusions that are greater on the left. The heart is partially obscured on the left but
appears to be enlarged. B, Computed tomography confirms bilateral pleural effusions and reveals that the
apparent cardiac enlargement is the result of pericardial effusion. This patient had a known diagnosis of lupus
erythematosus. Effusions are the most common manifestation of lupus in the chest.

13. PLEURAL EFFUSION WITH MULTIPLE
MASSES
• Metastatic and mesothelioma
• CT- reveals mass obscured by the effusion
• History of asbestos exposure – mesothelioma likely

14. WITH SEGMENTAL AND LOBAR
OPACITIES
• Segmental or lobar opacities
• Post op patient – subsegmental atelectasis( extremely common) due to
thoracic splinting and mucous plug
• Thoracotomy – effusion
• Abdominal surgery – sympathetic effusion
• Late developed effusion – secondary to postpericardiotomy syndrome
or pulmonary embolism

15. PLEURAL EFFUSION WITH ATELECTASIS
• Very common in ICU
• Very large pleural effusion – compressive atelectasis, contralateral shift
• Common in coronary care

16. complete opacification of the left hemithorax
Also note the shift of the trachea, mediastinum, and heart to
the right. This is a large pleural effusion, with complete
atelectasis of the left lung. This appearance does not reveal
the cause of the
effusion but is an important observation because it often
indicates the need for urgent drainage

17. LUNG NEOPLASM
• Pleural effusion
• Segmental and lobar opacities with minimal symptoms
• Or more chronic history of slowly developing dyspnoea
• Cough and blood stained sputum, LOW over a month
• Endobronchial mass- cause atelectasis or obstructive pneumonia
• Lymphoma- less likely to have pleural effusion and pulmonary opacities
at initially but in late stage (DDx-opportunistic infection and
tuberculosis)

18. A, The opacity of the left hemithorax with shift of the mediastinum to the right is the result of a large
hydropneumothorax with an air-fluid level. The pneumothorax would suggest a bronchopleural fistula, but is
iatrogenic secondary to thoracentesis. The additional finding of superior lobulated lateral masses is the result of pleural
metastases.. In this case, the masses were obscured by the pleural effusion prior to the thoracentesis and are visible
because of the iatrogenic pneumothorax. B, The CT reveals a large inferior mass that has extended through the chest
wall. This is a Ewing sarcoma that has spread to the pleura, with malignant effusion and multiple pleural masses.

19. WITH HILAR ENLARGEMENT
• Unilateral hilar enlargement – middle age smoker – sug: primary lung ca
• Lymphoma
• Metastases
• Granulomatous infection
• Less likely fungal – histoplasmosis or corccidioidomycosis
• With enlarged proximal pulmonary vessels+hilar enlargement+effusion-
congestive heart failure( rarely PE)

20. PARAPNEUMONIC EFFUSION AND
EMPYEMA
• In response to pneumonia
• Parapneumonic effusion -Low WBC and low protein content-sterile
• Empyema- elevated WBC and high protein
• But radiologically – indistinguishable
• Empyema – suspected rapid and large accumulation

21. EMPYEMA
• Secondary to pneumonia
• Pharyngeal abscess
• Mediastinitis
• Abdominal infection
• Penetrating chest trauma
• Pulmonary resection
• Thoracostomy tube
• Sclerosis of malignant effusion
• Esophageal perforation

22. A, A patient with a clinical and laboratory diagnosis of pneumonia has
developed right localized medial and lateral pleural opacities. B, Computed
tomography confirms multiple loculated pleural fluid collections consistent
with empyema.

23. A, A patient with a clinical and laboratory diagnosis of pneumonia has
developed right localized medial and lateral pleural opacities. B, Computed
tomography confirms multiple loculated pleural fluid collections consistent
with empyema

24. CHRONIC OR RECURRENT PLEURAL
EFFUSION
• Isolated pleural effusion – non specific, secondary to many entities
• Infectious disease with no evidence of underlying pulmonary disease (
tuberculosis is notorious for this)
• Rheumatoid disease of pleura but only after extensive exclusion of
others
• SLE, granulomatosis with polyangitis, systemic sclerosis

25. MALIGNANT PLEURAL EFFUSION
• Know primary tumor
• Ca lung, Mesothelioma, ovarian carcinoma
• With multiple pleural nodule + effusion – metastasis
• Malignant effusion –also risk for opportunistic infections
• Treated with toxic drugs- malignant effusion must be differentiate from
empyema and drug reactions

26. This large left subpulmonic pleural effusion appears to
spread around the lateral pleura.
The right apical mass also appears to follow the pleura
and makes the diagnosis of metastases almost certain.
The history of renal cell carcinoma confirmed the
diagnosis

27. ABDOMINAL DISEASE
• Subphrenic abscess-air fluid level in right upper quadrent
• But no air diaphragm in some case of subphrenic abscess- USG or CT

28. TOP 5 DIAGNOSES
• Congestive heart failure
• Parapneumonic effusion
• Metastases
• Ascites
• Tuberculosis