Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: April Cases

Pediatric Chest X-Rays Of The Month
Nikki Richardson MD & Jennifer Potter MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs MD, Faculty Editor
Chest X-Ray Mastery Project
April 2020

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.

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

HPI: 8-year-old male with
history of TBI and VP shunt
presents for vomiting and
increased head banging
(which he usually does
when upset or in pain). On
exam vital signs are within
normal limits and patient
nontoxic appearing.

VP shunt coiled in abdomen
No VP shunt in neck or chest
nontoxic appearing.

Dx: VP Shunt Disconnection
VP shunt coiled in abdomen
No VP shunt in neck or chest
nontoxic appearing.

CXR After Neurosurgical
Repair.
Shunt Should Traverse Through
The Chest.

HPI: 16-year-old presents
with 4 days of fever, chills,
cough, chest pain. On
exam, the patient is febrile,
tachypneic and tachycardic.
No focal findings on lung
auscultation.

Dx: Pneumonia
Bilateral opacities
with 4 days of fever, chills,
cough, chest pain. On
exam, the patient is febrile,
tachypneic and tachycardic.
No focal findings on lung
auscultation.

Patient was admitted to
the hospital and later
developed an increasing
oxygen requirement. On
further discussion, the
patient admits to vaping
intermittently - last use 2
weeks prior.
A chest CT was obtained.

Dx: E-cigarette vaping
associated lung injury (EVALI)
Diffuse subpleural ground glass
opacities
16-year-old with a history
of intermittent vaping
develops worsening
hypoxia.

Since we last discussed EVALI in December 2019…

Latest Outbreak Information
Updated every Thursday
This complex investigation spans almost all states, involves over a thousand patients, and a wide variety o
brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new ca
being reported, which makes it more difficult to determine the cause or causes of this outbreak.
As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) h
been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.
Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware,
Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, M
Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Vi
More deaths are under investigation.
The median age of deceased patients was 49 years and ranged from 17 to 75 years.
Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019):
70% of patients are male.
The median age of patients is 23 years and ages range from 13 to 75 years.

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html
Check out the
section on the
CDC website
geared toward E
cigarettes and
children

HPI: 6-week-old presents with
cough and difficulty breathing
for 3 weeks. There is no fever.
The mother reports that the
patient becomes sweaty with
breastfeeding. On exam, the
patient requiring supplemental
oxygen, heart sounds are more
prominent on right, distant
breath sounds with a “gurgling”
noise on the left.
Many thanks to our friends in Tanzania for this case!

HPI: 6-week-old presents with
cough and difficulty breathing
for 3 weeks. There is no fever.
The mother reports that the
patient becomes sweaty with
breastfeeding. On exam, the
patient requiring supplemental
oxygen, heart sounds are more
prominent on right, distant
breath sounds with a “gurgling”
noise on the left.
Rightward mediastinal shift
Loops of bowel in left chest
Dx: Diaphragmatic hernia

with left elbow pain and
fatigue since yesterday.
Mother noticed left eye
drooping at approximately
01:00 this morning. On
exam, the patient has pupil
asymmetry with L < R as
well as swelling of the left
arm.

with left elbow pain and
fatigue since yesterday.
Mother noticed left eye
drooping at approximately
01:00 this morning. On
exam, the patient has pupil
asymmetry with L < R as
well as swelling of the left
arm.
Dx: Left apical mass
6.5 cm x 5.5 cm Mass

CT performed as an
inpatient to further
characterize the mass.
Differential: Neuroblastoma,
lymphoma, germ cell tumor,
thymoma
Mass arising out of the superior
and middle mediastinum
Mass effect on the trachea
Pathologic Dx: Neuroblastoma

HPI: 4-year-old with a past
medical history of renal
mass s/p resection
presents to the ED for 7
days of cough. The patient
became progressively
worse at home and parents
were concerned about
increased work of
breathing. On exam, the
patient is tachypeic and
tachycardic.

HPI: 4-year-old with a past
medical history of renal
mass s/p resection
presents to the ED for 7
days of cough. The patient
became progressively
worse at home and parents
were concerned about
increased work of
breathing. On exam, the
patient is tachypeic and
tachycardic.
Dx: Pulmonary metastasis
secondary to primary Wilm’s
tumor
Innumerable bilateral pulmonary
nodules

Most Common Primary Sites of Pulmonary
Metastatic Disease in Children
• Wilms tumor
• Neuroblastoma
• Rhabdomyosarcoma
• Osteosarcoma
• Ewing sarcoma
https://radiopaedia.org/articles/pulmonary-metastases?lang=us
Image Shutterstock

VISUAL DIAGNOSIS
Dx: Endotracheal tube in the
right mainstem bronchus
ETT terminates in right
bronchus
Completely opacified left lung
fields

What’s With These Kids?
For the next section, we will review a series of cases/images with a
unifying diagnosis. Try to identify the similarities and come up with the
diagnosis! After each series of cases, we will discuss the
pathophysiology and imaging characteristics of the diagnosis.
These images and cases have been graciously shared with us from our
collogues in the pediatric cardiovascular surgery department. We thank
you for your continued support of this project!

history of multiple
hospitalizations for URIs
presents for near syncope
after getting out of water
where he was holding his
breath. Mother also notes
that patient has had noisy
breathing his whole life
and intermittent apnea.
Exam reveals noisy
breathing but lungs clear to
auscultation

HPI: 6-year-old female with
history of tonsillectomy
and adenoidectomy
presents to urgent care for
increased work of
breathing and stridor.
Mother reports that
patient has been seen
almost yearly for similar
complaints. Physical exam
with tachypnea and
expiratory stridor.

HPI: 8-month-old male
presents for vomiting with
almost every feeding of
solid food. Gaining weight
appropriately. Mother
reports that patient had an
echo performed soon after
birth but she cannot recall
the results. Physical exam
is unremarkable.

HPI: 2-month-old male
presents for noisy
breathing. Noisy breathing
has been present since
birth. Expiratory stridor on
exam, otherwise
unremarkable.

HPI: 4-month-old
diagnosed with right aortic
arch and left ductus
arteroisus in utero presents
with cough, congestion and
noisy breathing. On exam,
patient with increased
work of breathing and
expiratory stridor.

So, What’s With These Kids??

Vascular Ring
• Anatomic variants of the aortic
arch encircle the trachea and/or
esophagus
• Symptoms are produced by the
extrinsic compression on the
trachea (stridor) or esophagus
(dysphagia)
• 12% are associated with
congenital heart disease
Backer, Carl L., et al. “Vascular Rings.” Seminars in Pediatric Surgery, vol. 25, no. 3, 2016, pp. 165–175., doi:10.1053/j.sempedsurg.2016.02.009.
Photo: https://www.chop.edu/conditions-diseases/vascular-ring

Vascular Ring: Embryology
• Remember this?!?
• Vascular rings develop because
of a failure of specific arches to
involute OR involution of the
incorrect arch
• Right aortic arch is most often
secondary to failure of right 4th
arch to involute
• Double arch occurs when left 4th
arch also remains patent
Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2,
2017.

Vascular Ring: Clinical Presentation
History
• Infants
• Noisy breathing
• Toddlers
• Difficulty swallowing food
• Noisy breathing with illness
• Older Children
• Recurrent URIs
Physical Exam
• Expiratory stridor
Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology ,
vol. 6, no. 2, 2017.

Vascular Ring: ED Evaluation
• Not all stridor is croup or airway
foreign body!
• History and Chart review
• Multiple presentations for stridor
with URI symptoms
• Physical Exam
• Listen to phase of stridor
• If expiratory, consider vascular ring
• Imaging
• Chest XR; PA and lateral
• Consider CT angiography chest if
significant distress
CT reconstructions from
Pediatric Cardiovascular
Surgery Department at
Levine’s Children’s Hospital

• 95% of patients with vascular
ring have a visible abnormality
on CXR
• Segmental tracheal deviation
• Anterior tracheal bowing on the
lateral projection
• Right sided aortic arch
• Absent left aortic contour
Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017.
Knipe, Henry, and Francis Deng. “Vascular Rings and Slings: Radiology Reference Article.” Radiopaedia, radiopaedia.org/articles/vascular-rings-and-slings?lang=us.
Vascular Ring: CXR

Vascular Ring: CXR Limitations
• Atretic or hypoplastic arch may
be too small to cause visible
displacement
• Thymus can cover aortic arches
• Lack of lateral view due to acute
illness/portable CXR
• If suspicion is high and patient
with respiratory distress,
consider CT angiography to
make diagnosis
Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017.

Vascular Ring: Preoperative Studies
• CT angiography OR MRI of the
chest
• Preoperative planning
• Echocardiogram
• 12% have associated congenital
heart defect
• Bronchoscopy
• Assess for tracheomalacia or other
tracheal pathology

Vascular Ring: Surgical Repair
Backer, Carl L., et al. “Trends in Vascular Ring Surgery.” The Journal of Thoracic and Cardiovascular Surgery, vol. 129, no. 6, 2005, pp. 1339–1347.,
doi:10.1016/j.jtcvs.2004.10.044.
• Based on data from 209 cases at Children’s Memorial Hospital at Northwestern
• Muscle sparing left thoracotomy; right sided approach can be used as anatomy on CT or MRI dictates
• If double arch anatomy, the lesser or atretic arch should be divided to release the vascular ring. If equally balanced, the
site of division is chosen by clamping one arch and measuring the blood pressure in the lower extremities. The
clamped arch that produces the lower blood pressure is then divided
• If Kommerrell diverticulum is present it should be resected and the left subclavian artery (LSA) should be transferred to
the left carotid artery (LCA)
• Tube thoracostomy is no longer recommended postoperatively

Summary Of This Month’s Diagnoses
• VP shunt disconnection
• E-cigarette vaping associated lung
injury
• Diaphragmatic hernia
• Apical lung mass: Neuroblastoma
• Innumerable pulmonary metastasis
secondary to Wilms Tumor
• Endotracheal tube in right mainstem
bronchus
• Vascular ring

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