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This is a 32-year-old gentleman who had

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presented to the ED with a fever that had been going on for quite some time.

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And AP and lateral were done in the ED.

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And you can see here what stands out very

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pronounced is a large opacification in the right upper lung zone.

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And I'm saying that it's really

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the right upper lobe, because right here is a really nice and clear demarcation

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of the the minor fissure and superior to that is going to be the right upper lobe.

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It looks like it is continuous with the mediastinum.

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Looking at the other lung fields,

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there may be a little bit of haziness here in the lower lung zone.

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And again, this is going to be some

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of the right middle lobe, as well as the right lower lobe.

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The left lung looks essentially clear.

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I don't see any large pneumothorax or large pleural effusion.

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There's no mediastinal shift.

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We see the aortic contour very nicely.

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The cardiac contour, it's not enlarge.

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But again, the mediastinum looks like it's probably a little full and it's hard

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to differentiate between this air space opacification.

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So we want to take a look at the lateral view,

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and again, that can be used for confirmation of where we are.

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So again, remember that the horizontal fissure is going to sit here and then

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superior to that, you're going to have the upper lobe.

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Right now there's a lot of arm tissue

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that's sitting here and it's hard to see through that.

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But you can kind of see through here that there is increased opacification.

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So the tech came back,

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had the patient lift the arms, and you can see a little bit better that there's all

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of this area that's filling in here that's not well-aerated.

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So again, localizing to the upper lobe. And this patient ended up getting a CT.

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So we can see, again, what we're really

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dealing with and further characterize the findings.

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I think many instances in the right clinical context with a finding like this,

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relatively young patient with a lot of extensive history,

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this could be pneumonia case done and follow up if symptoms don't improve.

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But certainly, with an elderly population

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or patients who've got higher risk factors for malignancy, something like this,

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there may be benefit to either doing a CT to characterize it better, to know

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what you're dealing with, or having a really low threshold

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for having this person come back in six to eight weeks,

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just to document that this was something that resolved with antibiotics.

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So again, the CT was ordered, contrast was given.

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And again, I have hopefully driven home the notion that you want to take advantage

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of the information that's on the scout view.

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So you can see really consistently here,

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again, that right upper lobe opacification.

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You can see some of the small air

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bronchograms that are coursing through there.

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The left lung is clear,

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but then you do have, and you can see a little bit better on this image,

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kind of increase opacification in other portions of the right lung.

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So whether we're looking at the right middle lobe and the superior segment

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of the right lower lobe, the CT will allow us to see that a little bit better.

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Again, the lateral view, the scout,

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you know, you're seeing a lot of the opacification here in the upper lobe.

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So let's take a look at the axial images.

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And we'll just start at the top or the bottom, but not at the top.

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So again, going through and looking

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at soft tissue windows, the thyroid looks normal.

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You're coming down through the mediastinum, taking a look at the aorta.

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It's normal in caliber.

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Contrast isn't really hitting it, so it's hard to really identify dissection

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or hematoma, but it looks normal. As you're going down below the diaphragm,

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just making a note of the vasculature.

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I do see here, at the edge of the film, a simple cyst in the kidney.

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Coming back up through

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and on the vascular side, we're not getting adequate opacification

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in the pulmonary arterial tree to really assess for pulmonary emboli,

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but this was not something that was optimized for that.

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When you get to the upper mediastinum, you begin to see here in the mediastinum,

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again, lots of nodes that are enlarged.

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So this one right here is paratracheal lymph node, it's quite enlarged.

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But we also see a lot of opacification here in the lungs.

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This could be reactive.

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It certainly could be reactive in an infectious sort of way.

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If this was malignancy,

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I would certainly be concerned around malignant spread to this lymph node.

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This is a 30 something year old patient.

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So thinking malignancy a whole lot less than an infection, given the presentation.

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So we looked at the soft tissue windows.

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Let's take a look at the lung windows,

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which will give us a sense of where involvement exists.

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So as we move up on the left, I'm just kind of moving through really quickly.

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And we see a peripheral nodule here.

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So we can use the Fleischner criteria for the follow up...

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the appropriate follow up for that finding.

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It looks like it's probably below 4mm, and otherwise healthy patient.

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There's not really much for us to do at this point.

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Coming back down on the left,

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we see really dense focal consolidation with air bronchograms coursing through this

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area leading to the airway with some degree of narrowing.

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We talked about the nodes,

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but you do appreciate here that there is involvement in both the superior segment

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of the right lower lobe as well as the right middle lobe.

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So multifocal involvement, some of this is less consolidated.

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It looks, you know, more reticulonodular in nature.

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Don't see any large pleural effusion or pneumothorax.

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The airway looks patent.

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And let's take a look at the bones,

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make sure that we're not seeing anything that looks aggressive or out of place.

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And the ribs look fine.

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The scapula looks fine.

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The vertebral body columns look fine.

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Again, if you're looking at the bones,

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while the axials are certainly helpful, I also like to look on the sagittal,

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because we're able to see heights and alignment,

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and it's hard to appreciate some of that on the axial views,

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particularly when you see chest findings like this, because we're used to really

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looking at them through a coronal image on the AP.

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Looking at it on a similar view on the CT

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is kind of helpful to kind of get your bearing in terms of what you are seeing.

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So, again, as we were, you know, looking at these

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enlarged lymph nodes, that fullness in the mediastinum, that makes more sense now.

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You can see the opacification is pretty dense that's sitting on the minor fissure.

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You can appreciate now the air bronchograms as well.

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On lung windows, you can kind of appreciate some

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of the involvement in the lower lobes, remembering that your lower lobe,

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the superior segment actually comes pretty far up in the lung field.

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So just because it's in the upper lung

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zone, doesn't necessarily mean it's just the upper lobe.

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And so, superior segment of the right lower lobe is pretty far superior.

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So you see involvement there.

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You can also appreciate more anteriorly

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in the right middle lobe, but there's also some involvement there as well.

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So this is a case of multifocal pneumonia,

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which was further characterized on CT, in a patient who comes in with fever.

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In a patient this age, I would probably favor something infectious in its nature.

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In a patient that was a little bit older

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with a slightly different presentation, if it was cough, if they were a smoker,

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you'd want to basically put some thought to, is this malignancy?

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Are these nodes just reactive or are they malignant?

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And what is an appropriate follow up for this patient?

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This is a young patient who did have a small pulmonary nodule that was probably

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below threshold by their Fleischner criteria.

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So there wouldn't be recommended follow up in this case because of that nodule.

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But certainly, from a clinical perspective,

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if this patient was not responding appropriately to the antibiotics,

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wasn't improving clinically, then reimaging would certainly be appropriate.

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So, lots of things to consider in this case.

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CT is an adjuvant with lots of things if you're seeing on plane film and you want

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to use it judiciously, but it does serve a purpose.