ser 2016 30 mts k sodhi
TRANSCRIPT
Dr. Kushaljit Singh Sodhi MD,PhDAdditional Professor
Department of Radiodiagnosis & ImagingPGIMER, Chandigarh
Approach to Pediatric Chest Imaging in ER
SER 2016
Radiological Modalities: Pediatric Chest
Chest X-rayFluoroscopyUltrasoundContrast Studies CT scanMRI
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Radiological Modalities: Pediatric Chest
Chest X-ray
Ultrasound
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Approach to Pediatric Chest in ER
Age of the child Clinical profile
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ALARA
Non-traumatic Chest
Appropriateness Criteria American College of Radiology(ACR)
-Appropriateness criteria and referral guidelines for the appropriate use of imaging examinations
Evidence based guidelines Developed by panel of experts and
criteria covers over 180 topics with nearly 850 variants
www.acr.org/ac
Thoracic Emergencies in children of different ages
Neonatal respiratory distress
Infant Pre-school :1-5 yrs School age: 5-12 yrs
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Thoracic Emergencies in children of different ages
Pathology Infant (<1 yr)
Preschool(1-5 yrs)
School child(5-12 yrs)
Congenital anomalies
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Infections + + +
Foreign bodies + +
Airleaks + +
Tumours + +
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Neonatal Respiratory Distress : Incidence
Neonatal respiratory distress occurs in 11-14 % of all live births
Incidence depends on gestational age
Babies< 30 wks: 60% Babies >34 wks: 6%
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Am Fam Physician 2007; 76:987-94Pediatrics:1999; 104:1229-46
Respiratory Distress in Neonate: Algorithm
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Medical Disease Surgical Disease
Respiratory Distress in Neonate: Algorithm
Medical Disease Surgical Disease
Preterm Full Term At Birth Postnatal Period
Hyaline Membrane
Disease
Transient Tachypnoea
Meconium Aspiration
Neonatal Pneumonia
CDHCPAM CLE
VascularRing/ Sling.
Medical Disease
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Approach to Medical Disease
Hyaline Membrane Disease (HMD)
AKA neonatal respiratory distress syndrome or surfactant deficiency syndrome
In premature infant– Insufficiency of surfactant
production – MC cause of resp distress in 60%
of babies <29 wks
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Develops typically before neonate is 4 hours old& persists>24 hrs of age
Hyaline Membrane Disease (HMD)CXR Findings: • Seen as reticulogranular
(ground-glass) appearance • Hypovolemic lungs
Key points: • Hyperinflation excludes HMD• Pleural effusions seldom seen
Ped Radiol:1997:27:26-31
Hyaline Membrane Disease
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Hyaline Membrane Disease: Post Surfactant
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1st Chest x-ray After 18 hours
Rapid response
Hyaline Membrane Disease:
Is there any role of Ultrasound?
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Sonography in HMD: Diagnostic Performance
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S.No Authors Reference Sensitivity Specificity
1. Bober, et al Med Sci Monit. 2006 ;12 : 440-6100% 92%
2. Copetti, et al Neonatology. 2008; 94: 52-9 100% 100%
3. Ahuja, et al (PGI study)
IJRI 2012:22;4: 279-283 84.2% 88%
Hyaline Membrane Disease: Role of Ultrasound
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Retrodiaphragmatic hyperechogenicity
Ultrasound in HMD
Increased retrodiaphragmtic hyperechogenicity
High sensitivity and specificity for HMD
Also used for follow up of HMD and prediction of BPD
Neonatology2008:94:52-9
Key points:
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IJRI 2012:22: 279-283Ahuja CK,Saxena A, SodhiKS, Kumar P,Khandelwal N
29 wks: 6 hour old
Day 14
Transient Tachypnea of Newborn Respiratory distress shortly after delivery (Term
babies)
Wet lung
Due to retained lung fluid – Caesarian section – No vaginal squeeze – Decreased function of pulmonary capillaries
and lymphatics
CXR Findings
Hyperinflation Small effusion Increased perihilar vascular markings Typically resolves within 24 – 48 hours
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Ultrasound inTransient Tachypnea of Newborn
Double lung point 100% sensitivity & specificity Diff. in lung echogenicity b/w
upper & lower lung fields
Neonatology:2007:91:203-9
Meconium Aspiration Syndrome (MAS)
Affects term and postmature neonates Occurs when infants take meconium
into their lungs during or before delivery
Three main complications – Blocking the airways– Decreasing oxygen exchange – Resulting in chemical
pneumonitis
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Meconium Aspiration Syndrome
CXR findings – Coarse opacities – Hyperinflation– No pleural effusion – Spontaneous
pneumothorax (20%)
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Acute complications: Air leakAir leak
– Pulmonary interstitial emphysema
– Pneumomediastinum– Pnuemopericardium– Pneumothorax
Pneumothorax in neonates Spontaneous or sec to
infection, mec asp, ventilation barotruama
Supine: Air in anteromedial and subpulmonic recesses
Spontaneous more in premature:
6% in premature 1-2% in term babies
Neonatal Pneumonia
Important cause Various Organisms Pulmonary
opacities/consolidation Non specific
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Respiratory Distress in Neonate: Algorithm
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Medical Disease Surgical Disease
Approach to Surgical Disease
CXR: Detect LesionCT: Diagnosis + Characterization +Pre-op evaluationUSG: No definite role
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Sodhi KS: Acta Paediatr. 2014:103:807-11
Congenital Anomalies Lung
– Lobe: – Segment– Focal
Diaphragm
Mediastinum– Vessels
Agenesis/ Aplasia/ Hypoplasia
CCAM, CLE, Sequestration
• Vascular Ring/ Sling
• Diaphragmatic Hernia
30Sodhi KS,etal :Pediatr Emerg Care. 2005 :21:854-6.
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Pulmonary Agenesis / aplasia/ hypoplasia
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Agenesis Aplasia Hypoplasia
LungAgenesis
LungAplasia
LungHypoplasia
X LungX bronchus +++ Shift
X LungRudimentary bronchus +++ Shift
Rudimentary Lung √ bronchus, ↓+ Shift
X arteryX artery
√ artery, ↓
Sodhi KSIJRI 2001:145-46
Congenital Pulmonary Airway Malformation (CPAM)
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Congenital pulmonary airway malformation(CPAM)
Most common congenital /fetal lung lesion Failure of broncho-alveolar development Histologically- cysts lined by cuboidal or columnar
epithelium
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Thacker et al, current concepts and imaging findings, pg-171
Congenital Cystic Adenomatoid Malformation: CCAM
Congenital Pulmonary Airway Malformation, CPAMClassification (Stocker)
– Type I: (50%) Large cyst(s) (> 2 cm)– Type II: (40%) Multiple cysts (< 2 cm)– Type III: (10%) Solid
Stocker JT, Madewell JE, Drake RM. CCAM of the lung. Hum Pathol 1997; 8: 155 - 171
Type I Type II Type III
Classification(Stocker)
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Stocker JT. Histopathology 2002; 41(Suppl 2):424–30 Lee et al Radiology: Volume 247: Number 3—June 2008
1 Most common-70% 95% of cases involve only one lobe
2 20-25 % of CPAMs
3 8-10% of CPAMs
4 2-5 % of CPAMs
CPAM
Presentation: – Respiratory distress after birth
– Recurrent infection
– Incidental finding post natal cxr / prenatal US
CPAM
Radiological findings: Cystic mass (90%) Single lobe and unilateral
(>95%) Rare in RML If large, contralateral shift of
mediastinum
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CCAM Classification
Lee EY et al. Pediatr Radiol 2007
Type1 Type2 Type 3
CT Findings
40Type 4
Results from progressive over-distension of a pulmonary lobe
Associated with either intrinsic or extrinsic obstruction
Usually presents before 6 months of age (> 80%)
Not necessarily “lobar”
Congenital Lobar Emphysema
Congenital Lobar Hyperinflation
CLH : Clinical Presentation
Severity of symptoms depends on the amount of hyperinflation of the affected lobes (ball valve mechanism)
Resp distress: In newborn : 50 % < 6 months : 80% of cases.
MC site-LUL
42Biyyam DR,etal. Radiographics: 2010 Oct;30(6):1721-38
Congenital Lobar Hyperinflation
CXR Findings Hyperinflated lobe : hyperlucent Pulmonary vessels appear attenuated Surrounding pulmonary vessels displaced Adjacent lung is compressed & mediastinum
may be shifted to C/L side
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CLO
Congenital Diaphragmatic Hernia
Abnormal development of the diaphragm
Types – Bochdalek hernia – Morgagni’s hernia – Central tendon defects
Two major causes of death – Pulmonary hypoplasia – Pulmonary hypertension
Sodhi KS,etal: Afr J Paediatr Surg. 2011 :8:259-60.
Diaphragmatic Hernia Key Points: Early film:
– Radio-opaque hemithorax fluid-filled or collapse bowel
Later film: – Gas-containing bowel
Cystic appearance can change with time/ position
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At Birth After 24 hours
Congenital Diaphragmatic Hernia
CXR Findings – Bowel in chest – Mediastinal shift – Non-visualized diaphragm – Lack of bowel in abdomen – Position of NG tube
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Congenital Vascular Malformation and Tracheobronchial Obstruction
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Radiological investigation : CTA / MRA
1 month old girl c/o cyanotic attacks and noisy breathing since birth
Vascular RING : Trachea and esophagus completely surrounded
Double Aortic Arch: CT angiogram
Volume Rendering
Tracheal compression
MinIP VR: Air Structure
Pulmonary Sling: Incomplete surround
Trachea
Pulmonary sling
Type 2 sling
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Neonate with stridor
Aberrant rt. subclavian artery, forming a sling posterior to the trachea causing mild compression
Approach to Neonatal Respiratory Distress
CXR: Medical Disease
CXR + MDCT: Surgical Disease
MRI : Congenital Vascular lesions
Foreign Bodies in Children
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Foreign Body Aspiration
More common with food than toys
Highest risk between 1 and 3 years old(immature dentition – no molars, poor food control)
Common foods = peanuts, grapes, hard candies
Some foods swell with prolonged aspiration(may even sprout)
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Sodhi KS etal ;Acta Paediatr. 2010:99(7):1011-5We used low doses of 80-100 kVp and 50-80 mA
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Clinical Manifestations
Typically …Acute respiratory distress (now resolved or ongoing)
Witnessed choking period
Uncommonly …Cyanosis and resp arrest
Symptoms: cough, gag, stridor, wheeze, drool, muffled voice
Investigations
Xrays Lateral neck Chest – inspiratory, expiratory, decubitus views
Expiratory views
Overinflation (partial obstruction with inspiratory flow)
Volume loss with mediastinal shift towards obstructed side (partial obstruction with expiratory flow)
Atelectasis (complete obstruction)
Decubitus views
Normal Smaller volumes and elevated diaphragmon side down
Abnormal Hyperinflation or “normal” volumes indecub position
If suspected …Need a bronchoscope to rule out or
remove Foreign Body
Next?
Expiratory CXR
Decubitus views
Decubitus views
Approach to suspected foreign body
Equivocal cases: do an expiratory viewToddlers cannot !
Bilateral decubitus lateral films allows assessment of air-trapping caused by an inhaled foreign body.
Pediatric Chest Infections
Approach
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ROLE OF IMAGING
Detect the presence
Determine its location and extent
Determination of specific etiological agent
Exclude other thoracic causes of respiratory symptoms
Show complications
Donnelly LF. Imaging in immunocompetent children who have pneumonia. RCNA 2005
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PEDIATRIC CHEST RADIOGRAPHY
Most frequently performed radiographic examination in children
Projection - depending on the age SUPINE AP ERECT PA Lateral view - left lateral -abnormality in mediastinum/ lung base -localise lesion identified on frontal radiograph
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PEDIATRIC CHEST ULTRASOUND
Widely used and valuable in pediatric patients No need for sedation No radiation exposure Real time examination Portable
Brian D. Coley, MD. Chest Sonography in Children: Current Indications, Techniques, and Imaging Findings. RCNA 2011
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ATELECTASIS AND CONSOLIDATION
Atelectatic/consolidated lung transmits sound
Difficult to differentiate between the two
sonographic air bronchogram
sonographic fluid bronchogram
Occasionally homogenously echogenic with few visible bronchi - hepatization
ROLE OF USG
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PLEURAL EFFUSIONS
Sensitivity of USG > supine/decubitus radiographs for small pleural effusion
SIMPLE (serous/chylous) Anechoic fluid collectionCOMPLEX
(purulent/hemorrhagic) Multiple internal echoes Septations &loculations
Brian D. Coley, MD. Chest Sonography in Children: Current Indications, Techniques, and Imaging Findings. RCNA 2011
ROLE OF USG
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ROLE OF CT IN PEDIATRIC LRTI Complications of bacterial pneumonia To exclude underlying abnormality in recurrent
infection To evaluate immunocompromised children - normal
CXR but clinical suspicion To guide FNAC/biopsy DISADVANTAGES
• radiation exposure• requires sedation
Copley SJ. Application of computed tomography in childhood respiratory infections. British Medical Bulletin 2002
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PEDIATRIC CHEST CT
CT technique should be modified to reduce dose & acquisition time by:
-80 to 120 kVp -increasing pitch -decreasing gantry rotation time -reducing mAs according to weight
-smallest FOV ‘Justification & optimization’
Sodhi KS : Acta Paediiatr.2014:103:807-11
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EMPYEMA
Lenticular shape Uniform enhanching
wall (<5 mm) Compression of
adjacent lung Obtuse angle with
chest wall Separation of pleural
layers
ABSCESS
Round shape Thick irregular wall Pulmonary vessels
directly extends towards the lesion
Acute angle with chest wall
Locules of gas within the wall
“split pleura sign” and pulmonary compression are more specific for empyema as they are never seen in lung abscess
ROLE OF CT
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ADENOPATHY
Mediastinal or hilarNon specific finding in
the setting of pneumonia
Low attenuation necrotic centre on CECT - primary TB
ROLE OF CT
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MR IMAGING OF LUNG INFECTIONS
Characterise lung parenchymal, pleural, and lymph node inflammatory abnormalities
To evaluate suspected, acute complications of pneumonia
Absence of ionising radiation –Benefit children with chronic lung conditions and recurrent infection
Sodhi KS et al : J MRI 2016:43:1196-1206Sodhi KS et al : Leuk Lymph 2016:57:70-5
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Sodhi KS et al : J MRI 2016:43:1196-1206Sodhi KS et al : Leuk Lymph 2016:57:70-5
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COMMON BACTERIAL PNEUMONIAS IN CHILDREN
COMMON BACTERIA RADIOGRAPHIC PATTERN
Streptococcus pneumoniae Partial lobar consolidation, round pneumonia
Group A streptococci Segmental bronchopneumonia
Staphylococcus aureus Lobular bronchopneumonia, pneumatocoele, pleural effusion, empyema
Bordetella pertussis Bronchopneumonia, “shaggy heart” appearance
Chlamydia trachomatis Young infant. B/L patchy consolidation and hyperaeration
Mycoplasma pneumoniae School age. Segmental interstitial/airspace opacities
ADLER B, EFFMANN EL. PNEUMONIA AND PULMONARY INFECTION. IN, CAFFEY’S PEDIATRIC DIAGNOSTIC IMAGING, 11TH EDITION
Types of Pulmonary TB
Post primary Primary
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Primary TB Seen in patients not previously exposed to M
tuberculosis Infants and children< 5 years Usually self-limiting 4 main entities:
1.Parenchymal2.Nodal3.Pleural effusion4.Milliary
Ghon focus : primary parenchymal focus Ghon complex: combination of Ghon focus andenlarged draining LNs
Eur J Radiol 2004;51:139 –149.
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Lymphadenopathy Radiological hallmark of primary TB
Prevalence decreases with age
Seen in upto 96% of children and 43% of adults
MC sites – Rt. paratracheal and hilar nodes(UL)
Bilateral in about 1/3rd of the cases
Can be the sole radiographic feature
(more common in infants)
Int J Tuberc Lung Dis 2004:8:392–40286
Lymphadenopathy CT scan more sensitive than CXR
Features:
1.Nodes > 1cm in diameter
2.Central low attenuation with peripheral rim
enhancement
3. Airway compression by enlarged mediastinal lymph
nodes common in children< 5 years of age.
Eur J Radiol 2005;55:158 –172, Pediatr Pulmonol2008;43:505-10
Int J Tuberc Lung Dis 2004;8:392-402
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No contrast injections on MRI
Role of MRI in TB: Lymph node evaluation
MRI: Sensitivity and specificity of 100% for enlarged L nodes (short axis>1cm) Sodhi KS etal: J MRI,2016
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Parenchymal disease in Primary TB
Segmental/lobar distribution
Lower & middle lobe predominance
Indistinguishable from bacterial
pneumonia
Resolution without scarring – 2/3rd of the
cases.
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MILIARY TB
Miliary TB” (Latin word “miliarius,” -millet seed)
~2-6% of the patients with TB
Can occur in both primary and post-primary disease, more
frequent in latter.
Within 6 months of initial exposure
Elderly, infants, immunocompromised
Lymphohematogenous spread.
RadioGraphics 2007;27:1255–1273
WHO. Global Tuberculosis Control: Surveillance, Planning, Financing. Geneva: WHO; 2008.
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MILIARY TB
CXR: may be normal at onset
– diffuse 2-3 mm nodules with slight
lower lobe predominance (85%)
CT
– more sensitive, early detection
– small random nodules(MC)
– ground glass opacities91
Post Primary TB
Occurs in patients previously sensitized to M tuberculosis.
Refers to both reinfection and reactivation of TB. Adolescence & adulthood
Progressive, with cavitation as its hallmark.
Manifest as parenchymal disease, airway involvement, and pleural extension
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Post Primary TB
Distinguishing features of post-primary tuberculosis:
1.Predilection for the upper lobes2. Absence of lymphadenopathy3.Cavitation
AJR2008; 191:834–844.
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VIRAL PNEUMONIASRNA VIRUSES RADIOGRAPHIC PATTERN
RSV HA, BWT, AT, +/- BPParainfluenza HA, BWT, ATInfluenza BPMeasles BP, adenopathyHIV Opportunistic infections,
LIP/PLH
DNA VIRUSES RADIOGRAPHIC PATTERN
Adenovirus BP, BWT, AT, HA. Bronchiectasis and bronchiolitis obliterans
Cytomegalovirus Interstitial pneumonitis, alveolar opacities
Varicella BP, calcificationEpstein-barr virus Adenopathy, LIP/PLHPapillomavirus Nodules +/- cavitation
HA: HYPERAERATIONBWT: BRONCHIOLAR WALL THICKENINGAT: ATELECTASISBP: BRONCHOPNEUMONIA
ADLER B, EFFMANN EL. PNEUMONIA AND PULMONARY INFECTION. IN, CAFFEY’S PEDIATRIC DIAGNOSTIC IMAGING, 11TH EDITION
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FUNGAL PNEUMONIASINFECTION RADIOGRAPHIC
APPEARANCEActinomycosis Lung, nodal, pleual
disease, chest wallNocardia Cavitating nodules,
irregular consolidationBlastomycosis, Cryptococcosis
Consolidation, cavitation, nodules
Candidiasis Bronchopneumonia, nodules
Aspergillosis, invasive Bronchocentric/angiocentric lesion, “halo sign”, “air crescent sign”
Coccidioidomycosis Simulates TB. Thin walled cavities
Histoplasmosis Simulates TB
ADLER B, EFFMANN EL. PNEUMONIA AND PULMONARY INFECTION. IN, CAFFEY’S PEDIATRIC DIAGNOSTIC IMAGING, 11TH EDITION
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PARASITIC INFECTIONS
PARASITIC AGENT RADIOGRAPHIC PATTERN
Pneumocystis jirovecii Progressive bilateral perihilar edema and consolidation
Paragonimus westermani/lung fluke
Patchy/homogenous lung opacity, may calcify, pleual effusions common
Echinococcus Single/multiple round mass lesions, rupture and abscess formation
Toxocara cati and canis Granulomatous lung opacities
ADLER B, EFFMANN EL. PNEUMONIA AND PULMONARY INFECTION. IN, CAFFEY’S PEDIATRIC DIAGNOSTIC IMAGING, 11TH EDITION
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ROUND PNEUMONIA
Children < 8 years Solitary Well-defined borders Often in the perihilar region
or posteriorly in the lungs. Radiologic follow-up after 2-3
weeks to document interval resolution
SUPPURATIVEPARENCHYMALCOMPLICATIONS
COMPLICATIONS OF PNEUMONIAACUTE
CAVITARY NECROSIS, ABSCESS,
PNEUMATOCELE
PULMONARY GANGRENE
BRONCHOPLEURAL FISTULA
PLEURAL EFFUSIONS, EMPYEMA
PNEUMOTHORAX
CHRONIC
BRONCHIECTASIS
BRONCHIOLITIS OBLITERANS
FIBROTHORAX
TRAPPED LUNG
FIBROSING MEDIASTINITIS
Eslamy HK, Newman B. Pneumonia in Normal and Immunocompromised Children: An Overview and Update. Radiol Clin N Am 49 (2011) 895–920
Approach to child with acute respiratory infection
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Always compare with previous imaging to R/O congenital malformations
Wait as LONG AS POSSIBLE for follow up radiographs (2-4 weeks to clear). Recommended in CF/sickle cell anemia/round pneumonia
Our main role is to EXCLUDE bacterial pneumonia, not CONFIRM it, hence EXCLUDE children NOT requiring antibiotics
O2 saturation <94%, RR>60/min, nasal flaring, reduced breath sounds have statistically significant correlation with radiographic diagnosis of pneumonia
Also consider in atypical presentation: Malaise, irritability, headache, chest/abdominal painFEVER, COUGH,
WHEEZING, TACHYPNEA, CHEST
RETRACTIONS
CHEST RADIOGRAPH SHOWS PNEUMONIA
BACTERIAL/VIRAL
FAILURE OF PNEUMONIA TO CLEAR?
PLEUTAL/PARENCHYMAL
COMPLICATIONS
PNEUMONIA MIMICS?? CAUSE OF
PNEUMONIA??
CHEST RADIOGRAPH NORMAL
CT IN IMMUNOCOMPROMISED
CHILDREN
Imaging in Immunocompetent Children Who Have Pneumonia. Radiol Clin N Am 43 (2005) 253 – 265
Chest XRAY recommended for
diagnosis & management
decisions
CECT/USG depending on the clinical scenario
Other causes of acute respiratory distress in children
S.No Cause Recommended Investigation of choice
1 Pulmonary Embolism CTA /MRA
2 Trauma CXR -----Spiral CT
3 Masses / Tumours CXR----MDCT/ MRI
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10 years old boy, with a known diagnosis of Acute myeloid leukemia(AML).Chest radiograph reveals mediastinal mass, with moderate left pleural effusion.
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Imaging in Pulmonary Embolism
CT -PA 3D GRE True FISP
Conclusion
Approach to Pediatric Chest in ER Age of the child Clinical profileChest X-rayUltrasound: Pleural effusionCT & MRI: Congenital & TumoursALARA
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There are no seven wonders of the world in the eyes of a child. There are seven million. ~Walt Streightiff
THANK YOU!