Drs. Claire Milam and Alyssa Thomas are Emergency Medicine Residents and interested in medical education. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides on: • Pneumothorax • Non-cardiogenic Pulmonary Edema • COVID – 19 • Right Lower Lobe Pneumonia • Diaphragmatic Hernia • Lung Abscess • Miliary Tuberculosis • Asbestosis

1. Adult Chest X-Rays Of The Month
Alyssa Thomas MD & Claire Milam MD & Travis Barlock MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project™
June 2020

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Process
 Many are providing cases and these slides are shared with all contributors.
 Contributors from many CMC/LCH departments, and now from EM
colleagues in Brazil, Chile and Tanzania.
 Cases submitted this month will be distributed next month.
 When reviewing the presentation, the 1st image will show a chest X-ray
without identifiers and the 2nd image will reveal the diagnosis.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. 52-Year-Old Male
Presents After A
Motor Vehicle
Collision (MVC)

8. Diagnosis: Pneumothorax
Don’t forget to look at
the costophrenic angles!
Deep Sulcus Sign
52-Year-Old Male
Presents After A
MVC

9. Diagnosis: Pneumothorax

10. 52-Year-Old Male
Presents After A MVC
with Pneumothorax
Re-expansion of right lung after
pigtail catheter placement

11. 33-Year-Old Male
Presents After
Being Found
Poorly Responsive.
He Was Given 5mg
Of Naloxone
What Do You See?

12. Diagnosis: Non-cardiogenic
Pulmonary Edema
33-Year-Old Male
Presents After
Being Found
Poorly Responsive.
He Was Given 5mg
Of Naloxone

13. Non-
Cardiogenic
Pulmonary
Edema with
Use of
Naloxone
Citation: Farkas A, Lynch MJ, Westover R, et al. Pulmonary Complications of Opioid Overdose Treated
With Naloxone. Ann Emerg Med. 2020;75(1):39-48. doi:10.1016/j.annemergmed.2019.04.006
Due to:
Negative pressure resulting from inspiration
against a closed glottis
Increased capillary permeability
Increased pulmonary arterial pressure caused
by catecholamine surge from precipitated
withdrawal or sudden cerebral recognition of
hypoxia
Noncardiogenic Pulmonary Edema has been
Theorized to Occur via a Variety of Mechanisms:

14. This is a retrospective, observational, cross-sectional study
• A total of 485 (26.5%) cases had pulmonary complications
• Patients receiving more than 4.4mg of naloxone experienced
pulmonary complications 42% of the time compared with 26%
for those receiving smaller doses
• Patients receiving an initial naloxone dose of greater than 0.4mg
also had higher rate of pulmonary complications compared with
those who received less
Multivariable analysis of patient factors
associated with pulmonary complications
Methods: Patients administered naloxone in the out-of-hospital setting
and subsequently transported to Emergency Departments were
evaluated for pulmonary complications
Results:

15. • 24 cases of pulmonary edema with 18 (1.2%) of them being
related to opioid overdose
• 8 (44%) treated with positive-pressure ventilation, intubation
or both
• 10 (56%) received supplemental oxygen
• 1 (5%) had radiographic evidence of pulmonary edema, but no
hypoxia requiring supplemental oxygen
Specific Pulmonary Edema Results:

16. The risk of pulmonary edema appeared to be higher in groups receiving greater than 4.4mg of
total naloxone (OR 2.23, 95% CI .65 to 7.60)
Or
when the initial dose was greater than 0.4mg (OR 1.51; 95% CI 0.20 to 11.30) but were not
statistically significant
Specific Pulmonary Edema Results:
Citation: Farkas A, Lynch MJ, Westover R, et al. Pulmonary
Complications of Opioid Overdose Treated With Naloxone. Ann Emerg
Med. 2020;75(1):39-48. doi:10.1016/j.annemergmed.2019.04.006

17. 25-Year-Old Male
Presents with
Chest Pain

18. 25-Year-Old Male
Presents with
Chest Pain
Diagnosis: Right Lower Lobe (RLL)
Pneumonia

19. 78-Year-Old Male
Presents for
Evaluation of
Abdominal Pain
What do you notice?

20. 78-Year-Old Male
Presents For The
Evaluation Of
Abdominal Pain
Calcified Pleural
Plaques
Blunting Of The
Costophrenic
Angles

21. Calcified Pleural
Plaques
Diagnosis: History of
Asbestosis Exposure
78-Year-Old Male
Presents For The
Evaluation Of
Abdominal Pain
Blunting Of The
Costophrenic
Angles

22. 51-Year-Old Male
With A Prior
COVID-19
Infection Presents
With Chest Pain

23. Diagnosis: Lung Abscess
51-Year-Old Male
With A Prior
COVID-19
Infection Presents
With Chest Pain

24. AP Lateral

25. Air-Fluid Level: If It’s Flat There’s Air In There!

26. CT Imaging

27. 38-Year-Old Female
Presents With
Shortness Of Breath

28. Diagnosis: RLL Pneumonia,
COVID (+)
38-Year-Old Female
Presents With
Shortness Of Breath

29. The Patient Decompensates And Requires ECMO
38-Year-Old Female
Presents With
Shortness Of Breath

30. Decannulated And Extubated After 11 Days Of ECMO

31. 22-Year-Old Male Presents
With Influenza Like Illness
(ILI) And Shortness Of Breath
Important Social History:
Our Patient Recently Immigrated From
Vietnam 2 years Prior To Presentation

32. Important Social History:
Our Patient Recently Immigrated From
Vietnam 2 years Prior To Presentation Diagnosis: “Left Airspace Opacity”
22-Year-Old Male Presents
With Influenza Like Illness
(ILI) And Shortness Of Breath

33. Important Social History:
Our Patient Recently Immigrated From
Vietnam 2 years Prior To Presentation
22-Year-Old Male Presents
With Influenza Like Illness
(ILI) And Shortness Of Breath
What Should You Consider?

34. Important Social History:
Our Patient Recently Immigrated From
Vietnam 2 years Prior To Presentation
22-Year-Old Male Presents
With Influenza Like Illness
(ILI) And Shortness Of Breath
What Should You Consider?
Notice The
Tubular Lucencies

35. Important Social History:
Our Patient Recently Immigrated From
Vietnam 2 years Prior To Presentation
22-Year-Old Male Presents
With Influenza Like Illness
(ILI) And Shortness Of Breath
Diagnosis: Miliary Tuberculosis

36. Diagnosis: Miliary Tuberculosis

37. Notice:
1. The “millet seed”
appearance of
the parenchyma
in the right lung
2. The cavitary
lesions in the left
lung

38. Primary vs.
Miliary
Tuberculosis
 Tuberculosis [TB] is infection by Mycobacterium
tuberculosis bacilli.
 Primary TB is the initial infection of the bacilli,
often in the lungs.
 Miliary TB is tuberculosis infection that has
disseminated to other organs, often liver,
spleen, bone, and brain. (i.e. bacteremia).
 Miliary TB can be from hematogenous spread
from primary focus, or from reactivation of
latent TB.
Citation: Sahn S, Neff miliary tuberculosis. The American Journal of Medcine. 1974;56(4):495-
505. doi: https://doi.org/10.1016/0002-9343(74)90482-3

39. History of
Miliary TB
 The term “miliary” historically comes from the
radiographic finding of 1-2mm nodules
scattered among both lung fields.
 It was first described over 100 years ago and
thought to look like “millet” seeds.
 Each “seed” was where the blood had carried
the infection and it settled in that area of the
lungs.
 Think of military TB as bacteremia, and though
it often includes the classic CXR findings due to
pulmonary involvement (as it was named for),
you can have disseminated disease that does
not involve the lungs.
Citation: Manson, P., Farrar, J., Hotez, P. J., & Junghanss, T. (2014).
Tuberculosis. In Manson's tropical diseases. Edinburgh: Saunders Elsevier.

40. Pulmonary Tuberculosis on CXR
Miliary TB is not as easily diagnosed on CXR as
findings can be subtle.
One study had three chest radiologists review
71 CXRs of known miliary TB patients and
identified 59-69% of them.
Citation: Kwong JS, Carignan S, Kang EY, Müller NL, and FitzGerald JM:
Miliary tuberculosis. Diagnostic accuracy of chest radiography. Chest 1996;
110: pp. 339-342
Findings on CXR
• Consolidation
• Cavitation
• Pleural Effusion
• Hilar and Mediastinal Lymphadenopathy
• Pneumatocele
• Atelectasis
• Disseminated Miliary Disease
• Empyema
• Fibrosis
• Upper lobe lesions
• Spontaneous pneumothorax
• Normal – no findings
Citation: Woodring JH, Vandiviere HM, Fried AM, Dillon ML, Williams TD, and
Melvin IG: Update: the radiographic features of pulmonary tuberculosis. AJR
Am J Roentgenol 1986; 146: pp. 497-506

43. 42-Year-Old Male With
COVID (+) Who Presents
With Shortness of Breath

44. 42-Year-Old Male With
COVID (+) Who Presents
With Shortness of Breath
Diagnosis: Left Spontaneous Pneumothorax
With Bilateral Opacities

45. Diagnosis: Left Spontaneous Pneumothorax
With Bilateral Opacities
Also: Notice The
Subcutaneous Emphysema On
The Right And In The Neck
Bilaterally
(Despite This Being A Left
Sided Pneumothorax)
Notice The lack
Of Lung
Markings.
42-Year-Old Male With
COVID (+) Who Presents
With Shortness of Breath

46. Notice the Interval Change of the Lung Markings As
The Pneumothorax Is Worsening

47. Now Intubated With Left-Sided Chest Tube
42-Year-Old Male With
COVID (+) Who Presents
With Shortness of Breath

48. 55-Year-Old Male
Presents With
Dyspnea And Chest
Pain

49. 55-Year-Old Male
Presents With
Dyspnea And Chest
Pain
Diagnosis: Diaphragmatic Hernia

50. Notice the NG Tube Location
Diagnosis: Diaphragmatic Hernia

51. Summary Of Diagnoses This Month
 Traumatic Pneumothorax
 Non-Cardiogenic Edema
 COVID-19
 Right Lower Lobe Pneumonia
 Diaphragmatic Hernia
 Asbestosis Exposure
 Lung Abscess in COVID (+)
 Miliary Tuberculosis
 Spontaneous Pneumothorax in
COVID (+)

52. See You Next Month!