Table Of ContentI
II
III
The Chest X-Ray
Differential Diagnosis in Conventional Radiology
Francis A. Burgener, M.D. Martti Kormano, M.D. Tomi Pudas, M.D.
Professor of Radiology Formerly Professor and Chairman Department of Radiology
University of Rochester Department of Radiology University of Turku
Medical Center University of Turku Turku, Finland
Rochester, N.Y., U.S.A. Turku, Finland
2nd revised edition
498 illustrations
Thieme
Stuttgart · New York
IV
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V
Preface
Conventionalradiographyremainsthebackboneinthoracic wasupdated,manyillustrationsreplacedandlargenumbers
radiology despite the advent of newer and more exciting ofnewillustrationsadded.
imaging techniques such as computed tomography, high A changing of the guard has also taken place. Since Dr.
resolution computed tomography, magnetic resonance im- Martti Kormano’s professional endeavors do no longer in-
aging and most recently positron emission tomography. In cludeclinicalradiology,hefeltnolongeruptothetasktoup-
contrast to many of these newer methods, conventional datehisoriginalcontributionstothetext.Hewashowever
radiographyispracticednotonlybyradiologistsbutalsoby very fortunate to find in Dr. Tomi Pudas a very talented
a large number clinicians and surgeons. With each exami- young radiologist to take over the revision of the chapters
nation, one is confronted with radiologic findings that re- originallypreparedbyhim.
quireinterpretationinordertoarriveatageneraldiagnos- Ihopethisneweditionwillbeaswellreceivedasitspre-
tic impression and a reasonable differential diagnosis. To decessors in the past that produced several spin-off books
assist the film reader in attaining this goal this book is andweretranslatedintofiveforeignlanguages.Theconcept
based upon radiographic finding unlike most other text- ofanimagingpatternapproachintabularformratherthana
books in radiology that are disease oriented. Since many diseaseorientedtextwasintroducedin1985withtheorigi-
diseases present radiographically in a varicty of manifesta- nal edition and has since been adopted by many authors. I
tions some overlap in the text is unavoidable. To minimize feel complimented by the old cliché, “imitation is the
repetition the differential diagnosis of a radiographic find- sincerestformofflattery.“
ings is presented in tabular form whenever feasible. Most Thisbookismeantforphysicianswithsomeexperiencein
tablesdonotonlylistthevariousdiseasesthatmaypresent chestradiologywhowishtostrengthentheirdiagnosticacu-
radiologicallyinaspecificpattern,butalsodescribeinsuc- men.Itisacomprehensiveoutlineofradiographicfindings
cinct form other characteristically associated radiographic and it should be particularity useful to radiology residents
findings and pertinent clinical data. Radiographic illustra- preparingfortheirspecialistexaminations,especiallysince
tionsanddrawingsareincludedtodemonstratevisuallythe theexposuretoconventionalradiographyduringtheirtrain-
radiographic features under discussion. ingcontinuouslydecreasedinthepastinfavorofnewerim-
The transition from film to digital radiography had the aging modalities. Any physician involved in the interpreta-
greatestimpactonconventionalradiologysincethepublica- tion of conventional chest radiograph examinations should
tionofthelastedition.Thischangehoweverdidnotaffect findthisbookhelpfulindirectproportiontohiscuriosity.
thewayradiologicdiagnosesareascertained.Sincethepub- Itismyhopethatthisneweditionwillbeaswellreceived
lication of the last edition in 1992 the name of a few dis- asthepreviousonesbymedicalstudents,residents,radiolo-
ordershaschanged(e.g.,histiocytosisXtoLangerhanscell gists and physicians involved in the interpretation of con-
histiocytosis) and a few disease are newly recognized (e.g. ventionalchestradiographswere.
severeacuterespiratorydistresssyndromeorSARS).These
facts were taken into account in the new edition. The text FrancisA.Burgener,M.D.
VI
Acknowledgements
Itisimpossibletothankindividuallyallthosewhohelpedto I wish to express also many thanks to Jeanette Griebel,
preparethethirdeditionofthistextbook.Iwishtoacknowl- IonaMackey,andMarcellaMaierfortheirassistanceinpre-
edgethestaffofThieme,inparticularDr.CliffordBergman paringthereferencesandtoShirleyCappielloforhergeneral
andMr.GertA.Krüger. assistance. Last, but not least, I am most grateful to Alyce
IamdeeplyindebtedtoDr.GertrudGollman,Steinacham NorderwholefttheUniversityandmeafter30yearsforthe
Attersee,Austria,whotranslatedthelasteditionofthistext richness of the industry. She is the only person capable of
into German and suggested many alterations and correc- deciphering my longhand and, as in the past, did a superb
tions,whichhavebeenincorporatedintothisnewedition. job in typing, editing, and proofreading the manuscript of
My gratitude goes to all the radiologists whose coopera- theneweditionofthistext.Despiteherheavyworkloadas
tion made available illustrative cases to compliment the executive assistant in her new endeavor. Alyce was kind
originalcollectionortoreplaceolderillustrations.Iamin- enoughtoperformthistaskinhersparetime,forwhichIam
debtedtoDrs.StevenP.Meyers,JohnnyU.V.Monu,andGwy greatlyappreciative.
Suk Seo, all staff members of the University of Rochester FinallyIappreciatethesupportofmywifeTherese,who
RadiologyDepartment,andtotheformerresidentsDrs.John has generously given her precious family time for the pre-
M. Fitzgerald and Wael E. A. Saad for providing selected parationofthisbook.
cases. FrancisA.Burgener,M.D.
I would like to express my deepest gratitude to honorary radiology.ThemanyfascinatingdiscussionsIhavehadwith
professor Martti Kormano who invited me to carry on his Drs. Seppo Kortelainen and Teemu Paavilainen brought me
workinthisnewedition.Icontinuetoadmirethemassive muchdelight,onnon-radiologicaltopicsasmuchasonpro-
workthatheandDr.Burgeneroriginallyputintotheproject fessionalsubjects.
intheearlynineteen-eighties.Thehundredsofhourswhich Ialsoexpresssincerethankstothestaffofthepublishers,
Dr. Kormano and I have spent together editing this edition Thieme, especially to Dr. Clifford Bergman and Mr. Gert
havebeenagreatpleasure.Itwasafascinatingtimeinmy Krüger. Finally, much gratitude is due to Mr. Markku
life. Livanaien for his valuable assistance with technical ques-
IespeciallywanttothankDrs.KimmoMattilaandSeppo tions,andtoMs.PirjoHelankoforallherhelpwithgeneral
Koskinen for introducing me to musculoskeletal radiology, matters.Manyotherindividualshelpedinvariouswayswith
and for their extraordinary teaching and support. Many thisproject,andthoughIcannotnamethemall,Iamgrateful
thanks also belong to Drs. Erkki Svedström, Risto Elo, and fortheircontributions.
PeterB.Deanforencouragingmeonmywayinthefieldof TomiPudas,M.D.
VII
Contents
1 Cardiac Enlargement ................... 3 7 Pulmonary Edema and Symmetrical
MarttiKormanoandTomiPudas Bilateral Infiltrates ..................... 143
FrancisA.Burgener
2 Mediastinal or Hilar Enlargement ......... 43
MarttiKormanoandTomiPudas 8 Pulmonary Nodules and Mass Lesions ..... 157
FrancisA.Burgener
3 Pleura and Diaphragm ................. 71
MarttiKormanoandTomiPudas 9 Pulmonary Cavitary and Cystic Lesions .... 175
FrancisA.Burgener
4 Intrathoracic Calcifications .............. 83
MarttiKormanoandTomiPudas 10 Hyperlucent Lung ..................... 189
MarttiKormanoandTomiPudas
5 Alveolar Infiltrates and Atelectasis ........ 95
FrancisA.Burgener References ............................... 202
6 Interstitial Lung Disease ................ 119 Index ................................... 203
FrancisA.Burgener
VIII
Abbreviations
ACTH adrenocorticotropichormone LIP lymphoidinterstitialpneumonitis
AIDS acquiredimmunedeficiencysyndrome LL lowerlobes
LLL leftlowerlobe
ALL acutelymphoblasticleukemia
LLQ leftlowerquadrant
AML acutemyeloblasticleukemia
LUL leftupperlobe
ANCA antineutrophilcytoplasmoticautoantibodies LUQ leftupperquadrant
ANT anterior LV leftventricle
AP anteroposterior M male
APVR anomalouspulmonaryvenousreturn MAI Mycobacteriumaviumintracellulare
ARDS acuterespiratorydistresssyndrome MFH malignantfibroushistiocytoma
ATN acutetubularnecrosis ML middlelobe
AV arteriovenous MPS mucopolysaccharidosis
AVF arteriovenousfistula MR magneticresonance
AVM arteriovenousmalformation MRI magneticresonanceimaging
AVN avascularnecrosis NHL non-Hodgkinlymphoma
Bx biopsy NUC nuclearmedicine
CAD coronaryarterydisease PA posteroanterior
CAM cysticadenomatoidmalformation
PAPVR partialanomalouspulmonaryvenousreturn
CHF congestiveheartfailure
PATH pathology
CID cytomegalicinclusiondisease
PAVM pulmonaryarteriovenousmalformation
CLL chroniclymphaticleukemia
PCP Pneumocystiscariniipneumonia
CMV cytomegalovirus
PDA patentductusarteriosus
CNS centralnervoussystem
PE pulmonaryembolism
COPD chronicobstructivepulmonarydisease PET positronemissiontomography
CT computedtomography
PNET primitiveneuroectodermaltumor
DD differentialdiagnosis
PO peroral
DIC disseminationintravascularcoagulation
RA rheumatoidarthritis
DIP desquamativeinterstitialpneumonitis
RA rightatrium
EG eosinophilicgranuloma
RBC redbloodcell
F female
RDS respiratorydistresssyndrome
GE gastroesophageal
RES reticuloendothelialsystem
GIP giantcellinterstitialpneumonitis
RLL rightlowerlobe
Hb hemoglobin
RLQ rightlowerquadrant
HD Hodgkindisease
RML rightmiddlelobe
HIV humanimmunodeficiencyvirus RUL rightupperlobe
HRCT high-resolutionCT RV rightventricle
Hx history SARS severeacuterespiratorydistresssyndrome
IM intramuscular SLE systemiclupuserythematosus
IVC inferiorvenacava TAPVR totalanomalouspulmonaryvenousreturn
L left TB tuberculosis
LA leftatrium TNM tumor-node-metastasis
LCH Langerhanscellhistiocytosis UIP usualinterstitialpneumonitis
LE lupuserythematosus US ultrasound
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