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Case of the Month 09/06

30 year old female with no PMH presented with shortness of breath and fever for 2 days. She had had intermittent non-productive cough during this period and came to ED because of worsening sob. She denied chest pain, sick contacts or recent travel.

In ED, she was febrile to 102, had a heart rate in the 130s and O2 saturation of 94% on room air.

Q: How would you describe this CXR?

View answer

This is a diffuse interstitial infiltrate (as opposed to alveolar). You can tell that the markings are interstitial by looking at the very fine thin lines in the peripheral lung field. An alveolar infiltrate would tend to look more fluffy, “cloud-like,” and less linear. Below is a close up from Mettler: Essentials of Radiology textbook showing a close up of linear interstitial markings.

Q: In congestive heart failure, in what order do x-ray findings typically appear?

View answer

Cephalization (upper lobe vessels same size or larger than lower lobe vessels.)
Interstitial markings/Kerley b lines
Alveolar/airspace filling

Follow Up

The patient had a CT angio which was negative for PE (done because of a positive D-dimer), negative HIV test and negative urine antigens for legionella and strep pneumonia.

She also had negative blood cultures. She improved clinically on ceftriaxone and azithromycin and was discharged on hospital day 3. Repeat CXR for visit (for unrelated symptoms) below: