Premature newborn with respiratory distress syndrome and new abdominal distension on a ventilator

AXR of pneumoperitoneum in a patient with respiratory distress syndrome — CXR AP shows a bubbly branching appearance to the right lower lobe and overall increased lucency throughout the entire abdomen.

The diagnosis was pulmonary interstitial emphysema in the right lower lobe and pneumoperitoneum in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress syndrome and new abdominal distension on a ventilator

The diagnosis was pneumoperitoneum in a patient with respiratory distress syndrome.

Premature infant with respiratory distress on a ventilator

CXR of bilateral tension pneumothoraces and pneumomediastinum — CXR AP shows a large amount of lucency in the pleural spaces laterally and inferiorly to the right lung and superiorly and inferiorly to the left lung. There is air outlining the thymus and in the neck. The mediastinum remains in the midline.

The diagnosis was bilateral tension pneumothoraces and pneumomediastinum in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of bilateral tension pneumothoraces in a patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the lung bases bilaterally while the cardiac silhouette is very narrow and small in size. The mediastinum remains in the midline.

The diagnosis was bilateral tension pneumothoraces confirmed after bilateral chest tube placement in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of tension pneumothorax in patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the right pleural space and there is mediastinal shift to the left.

The diagnosis was a right tension pneumothorax in a patient with respiratory distress syndrome.

Premature infant with respiratory distress on a ventilator

CXR of pneumothorax in a patient with respiratory distress syndrome — CXR AP shows symmetrical ground glass appearance to the right lung and increased lucency throughout the left hemithorax with a suggestion of a left pleural edge laterally while the cross-table lateral CXR shows a large amount of lucency anterior to the heart.

The diagnosis was a large left anterior pneumothorax in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of basilar pneumothorax in a patient with respiratory distress syndrome — CXR AP shows a large amount of lucency in the left lung base and over the left hemidiaphragm with a chest tube in the center of it.

The diagnosis was a basilar pneumothorax in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of small bilateral pneumothoraces in patient with respiratory distress syndrome — CXR AP shows diffuse symmetrical ground glass opacity throughout the lungs along with increased lucency in the right lung base laterally and increased lucency distinctly outlining the left cardiomediastinal silhouette.

The diagnosis was bilateral small pneumothoraces which were confirmed with bilateral decubitus CXRs in a patient with respiratory distress syndrome.

Premature newborn on a ventilator

CXR of atelectasis in a patient with respiratory distress syndrome — CXR AP (above) shows symmetrical ground glass opacity in the lungs. CXR AP obtained after decreasing ventilator settings (below) shows interval decreased aeration of the right upper lobe.

The diagnosis was atelectasis caused by hypoventilation in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of a pneumothorax and a skin fold simulating a pneumothorax in a patient with respiratory distress syndrome — CXR AP shows a small amount of increased lucency laterally in the right lung base and increased lucency in the left lung apex and base. There is also a straight line running at an angle across the lower lateral left chest.

The diagnosis was a right basilar pneumothorax and a large left pneumothorax and a skin fold in the lower lateral left chest which were confirmed with bilateral decubitus CXRs in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of a skin fold simulating a pneumothorax in a patient with respiratory distress syndrome — CXR AP shows diffuse symmetrical ground glass opacity throughout the lungs and a straight line running at an angle across the lower lateral left chest.

The diagnosis was a skin fold in the lower lateral left chest and not a pneumothorax in a patient with respiratory distress syndome.

Premature newborn with respiratory distress on a ventilator

CXR of pneumomediastinum — CXR AP+lateral shows air around the thymus superiorly and air around the heart inferiorly. The diaphragm can be traced continuously across both images. There is also a small amount of air in the apex of the right pleural space.

The diagnosis was pneumomediastinum and a small right apical pneumothorax in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of pneumopericardium — CXR AP (above) shows a large amount of air around the heart. CXR AP obtained after pericardiocentesis (below) shows a decreased amount of air around the heart and the diaphragm can be continuously traced across the image.

The diagnosis was pneumopericardium in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

CXR of pulmonary interstitial emphysema — CXR AP shows a branching bubbly appearance to the right lung and a large amount of air in the right pleural space.

The diagnosis was pulmonary interstitial emphysema and tension pneumothorax in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress on a ventilator

The diagnosis was pulmonary interstitial emphysema in a patient with respiratory distress syndrome.

Premature newborn who has become more difficult to ventilate

The diagnosis was pulmonary interstitial emphysema and pneumomediastinum in a patient with respiratory distress syndrome.

Premature newborn who has received artificial surfactant

CXR of asymmetrical distribution of artificial surfactant in a patient with respiratory distress syndrome — CXR AP obtained just after birth (left) shows the lungs to be hypoexpanded with symmetrical ground glass opacity present throughout the lungs from their apex to their base. CXR AP taken after the administration of artificial surfactant (right) shows the right lung to now be normally expanded with clearing of the previously seen ground glass opacity while the left lung remains hypoexpanded with asymmetrical ground glass opacity present throughout it.

The diagnosis was asymmetrical distribution of artificial surfactant in a patient with respiratory distress syndrome.

Premature newborn who has received artificial surfactant

The diagnosis was symmetrical distribution of artificial surfactant in a patient with respiratory distress syndrome.

Premature newborn with respiratory distress

CXR of respiratory distress syndrome / surfactant deficiency disorder — CXR AP shows the lungs to be hypoexpanded with symmetrical ground glass opacity present throughout the lungs from their apex to their base.

The diagnosis was respiratory distress syndrome.

Our DDX For This Week Is

Newborn with a distended abdomen and bilious aspirates

Surgical image of jejunal atresia — Surgical image shows dilation of the proximal jejunum with a blind end (to the left) and a distal apple-peel deformity with extensive atresias of the jejunum and ileum (to the right).

The diagnosis was jejunal atresia.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager with juvenile idiopathic arthritis with neck pain and torticollis for 6 weeks

CT of atlanto-axial rotatory subluxation due to juvenile idiopathic arthritis — Axial images from a CT without contrast of the cervical spine shows the C1 vertebral body rotated to the left approximately 45 degrees (top) in relation to the C2 vertebral body (middle). A MIP image (bottom) better demonstrates the rotation of C1 on C2.

The diagnosis was atlanto-axial rotatory subluxation due to juvenile idiopathic arthritis.

Preschooler with fever and torticollis

CT of atlanto-axial rotatory subluxation due to retropharyngeal abscess — Axial images with bone windows from a CT with contrast of the neck shows the C1 vertebral body (above left) rotated approximately 30 degrees to the right in relation to the C2 vertebral body (above right). Axial image with soft tissue windows (below) from the same CT shows a low density fluid collection with an enhancing rim to the left of midline in the retropharyngeal space.

The diagnosis was atlanto-axial rotatory subluxation due to a retropharyngeal abscess.

Preschooler who developed torticollis after watching a video on their tablet with their neck flexed for 8 hours without moving

CT of atlanto-axial rotatory subluxation — 3D CT without contrast of the cervical spine shows the C1 vertebral body rotated to the left approximately 30 degrees in relation to the C2 vertebral body.

The diagnosis was atlanto-axial rotatory subluxation due to muscle spasm.