School ager with hypoxia who has Eisenmenger syndrome due to a ventricular septal defect and a brain abscess

CXR and CT of septic emboli in the lungs / septic pulmonary emboli — CXR AP (above) shows multiple round lesions of varying size throughout both lungs which on the axial CT with contrast of the chest (below) are shown to have indistinct margins.

The diagnosis was septic emboli in the lungs in a patient with Eisenmenger syndrome.

Infant with cough and decreased left ventricular ejection fraction

CXR and CT of anomalous left coronary artery from the pulmonary artery / ALCAPA — CXR AP (above) shows the left hemithorax is completely opacified with no mediastinal shift to the left and the pulmonary vascularity is congested. Axial CT with contrast of the chest (below) shows an extremely dilated left ventricle causing compression of the left mainstem bronchus and complete collapse of the left lung.

The diagnosis was anomalous left coronary artery from the pulmonary artery causing ischemic cardiomyopathy.

Young adult with recurrent pulmonary infections

Gross pathological image of bronchial atresia — Gross pathological image of a sectioned right middle lobe shows a dilated mucous filled airway (in white) distal to a focal area of an atretic bronchus.

The diagnosis was bronchial atresia.

Newborn with grunting

CXR of persistent pulmonary hypertension — CXR AP shows cardiomegaly and increased pulmonary blood flow.

The diagnosis was persistent pulmonary hypertension.

School ager with dyspnea

Angiogram of pulmonary ateriovenous malformation — CXR AP (upper left) shows an ill-defined mass in the right hilum. AP image from a selective injection of the right pulmonary artery from a pulmonary angiogram (upper right) shows a tangle of dilated arterial vessels comprising the mass. Arterial phase (lower left) and venous phase (lower right) AP images from a pulmonary angiogram demonstrate the early arterial appearance of the lesion and then its venous drainage back into the left atrium.

The diagnosis was pulmonary arteriovenous malformation.

School ager with heterotaxy syndrome and asplenia and bilious vomiting

CXR of heterotaxy syndrome and upper GI of malrotation without midgut volvulus — CXR AP (above) shows the cardiac apex to be in the right hemithorax and the gastric bubble to be in the left upper quadrant. AP image from an upper GI (below) shows the ligament of Treitz to be in the right upper quadrant. There is no evidence of duodenal obstruction. The proximal jejunum is also in the right upper quadrant.

The diagnosis was malrotation without midgut volvulus in a patient with heterotaxy syndrome.

Infant with heterotaxy syndrome and complex congenital heart disease and bilious vomiting

Upper GI of malrotation without midgut volvulus in heterotaxy — AP image from an upper GI shows the ligament of Treitz to be in the right upper quadrant. There is no evidence of duodenal obstruction. The proximal jejunum is also in the right upper quadrant. There is also gastroesophageal reflux.

The diagnosis was malrotation without midgut volvulus in a patient with heterotaxy syndrome.

Teenager with a chronic cough

Gross pathological image of bronchiectasis in cystic fibrosis — Gross pathological image of a sectioned lung shows marked dilation of the airways in the middle and lower lung with many of the dilated airways containing mucous within them.

The diagnosis was bronchietasis in cystic fibrosis.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Young adult who has gone from being acyanotic to now being cyanotic

CXR of Eisenmenger syndrome due to ventricular septal defect / VSD — CXR AP at 4 years of age (above) shows mild prominence of the pulmonary arteries bilaterally. CXR AP at 24 years of age (below) shows marked enlargement of the pulmonary arteries bilaterally with peripheral pruning of the pulmonary vasculature.

The diagnosis was Eisenmenger syndrome due to ventricular septal defect.

Newborn with respiratory distress, a heart murmur and a head bruit

US of vein of Galen malformation — Coronal grayscale US of the head (above left) shows a large round hypoechoic structure in the midline between the posterior horns of the lateral ventricles and above the cerebellum on the sagittal grayscale US (above right) which on color doppler (below) has turbulent blood flow within it.

The diagnosis was Vein of Galen malformation.

Cyanotic newborn

Angiogram of truncus arteriosus — AP image from an aortic root injection in an angiogram shows simultaneous opacification of a right aortic arch and the pulmonary artery arising from it.

The diagnosis was truncus arteriosus.

Cyanotic newborn

CXR of transposition of the great arteries / transposition of the great vessels / TGA — CXR AP shows increased pulmonary vascularity and cardiomegaly.

The diagnosis was transposition of the great arteries.

Cyanotic newborn

CXR of totally anomalous pulmonary venous return — CXR AP shows increased pulmonary vascularity and a normal sized heart with an upturned cardiac apex.

The diagnosis was total anomalous pulmonary venous return.

Cyanotic toddler

CXR of tetralogy of Fallot / TOF — CXR AP shows decreased pulmonary vascularity and a normal sized heart with the cardiac apex slightly upturned.

The diagnosis was tetralogy of Fallot.

Cyanotic newborn

CXR of pulmonary atresia with intact ventricular septum — CXR AP shows decreased pulmonary vascularity and mild cardiomegaly.

The diagnosis was pulmonary atresia with intact ventricular septum.

Acyanotic infant

Angiogram of patent ductus arteriosus / PDA — AP image from a ventricular injection in an angiogram shows simultaneous opacification of the aorta and main pulmonary artery.

The diagnosis was patent ductus arteriosus.

Cyanotic newborn

CXR of hypoplastic left heart syndrome / HLHS — CXR AP shows increased pulmonary vascularity and cardiomegaly.

The diagnosis was hypoplastic left heart syndrome.

Acyanotic infant with grunting

CXR of tachyarrythmia cardiomyopathy — CXR AP shows increased pulmonary vascularity and mild cardiomegaly.

The diagnosis was tachyarrythmia cardiomyopathy.

Acyanotic infant

CXR of AV canal / endocardial cushion defect — CXR AP and lateral shows hyperexpanded lungs, increased pulmonary vascularity and marked cardiomegaly.

The diagnosis was AV canal.

Acyanotic teenager

CXR of atrial septal defect / ASD — CXR AP shows mildly increased pulmonary vascularity and a normal heart size.

The diagnosis was atrial septal defect.

Our DDX For This Week Is

Toddler with a right suprarenal mass

Gross pathological image of extralobar pulmonary sequestration — Gross pathological images show a right-sided subdiaphragmatic / suprarenal mass similar in appearance to the lung above it (above left). When the aorta was opened (above right), the orifice of an arterial vessel supplying the mass was seen coming off of the aorta just above the tip of the upper hemostat on the right side of the aorta. The relationship of the feeding vessel off of the aorta to the mass is more clearly demonstrated on the specimen image (below).

The diagnosis was a subdiaphragmatic extralobar pulmonary sequestration.

Newborn with respiratory distress

CXR of pulmonary lymphangiectasia — CXR AP and lateral shows mild cardiomegaly and diffuse interstitial infiltrates with no evidence of pleural effusions.

The diagnosis was pulmonary lymphangiectasia.

Infant with respiratory distress

CXR and bronchogram and pulmonary angiogram of pulmonary agenesis — CXR AP and lateral (above) shows complete opacification of the left hemithorax and tracheal and mediastinal shift to the left and hyperexpansion of the right lung. CXR AP taken during a bronchogram (below left) shows absence of the left mainstem bronchus. AP image from a pulmonary angiogram (below right) shows a normal appearing right main pulmonary artery and absence of the left pulmonary artery.

The diagnosis was pulmonary agenesis.