Dr. Pepe Case 140 – Art of interpretation – SOLVED!

Dear Friends,

I am presenting today a new “Art of interpretation” case.
Radiographs belong to a 51-year-old with chest pain, dyspnea and D-dimer of 750.

1. Pulmonary infarct
2. Pneumonia
3. Chronic pulmonary changes
4. None of the above

What do you see? Come back on Friday to see the answer!

Click here to see the images

Click here to see the answer

Findings: the PA radiograph shows an ill-defined opacity in the right mid-lung field (A, white arrows) which looks intrapulmonary. There is blunting of the right costophrenic angle, indicative of pleural disease (A, red arrow).

The main diagnostic findings are seen in the lateral view. There are oblique posterior pulmonary strands (“crow’s feet”) (B, white arrow) which lead our attention to a posterior vertical white line (B, red arrows), which represents calcified pleura.
A negative finding is the absence of pulmonary disease in the lateral view.

These findings are better seen in the cone down views (C and D, arrows) .

Analysis of findings:
1. Apparent pulmonary disease in the PA radiograph
2. No visible pulmonary disease in the lateral view
3. Blunting of costophrenic angle with calcified posterior pleura
4. Crow’s feet

Summing up the findings: The apparent pulmonary disease in the PA view, which was not seen in the lateral view, together with chronic pleural disease (evidenced by blunting of the costophrenic angle and calcified posterior pleura) are highly suggestive of pleural disease simulating a pulmonary infiltrate.


Enhanced axial CT confirms the posterior calcified pleura (A, arrow), the lack of pulmonary infiltrate, and the crow’s feet adjacent to the diseased pleura (B, red arrow).
Crow’s feet are better seen in the coronal and sagittal reconstructions (C and D, red arrows), especially the sagittal view, which is practically identical to the lateral chest radiograph.

Final diagnosis: Pleural calcification simulating pulmonary infiltrate

(My heartfelt thanks to Dr. Eva Castañer for providing the CT images)

Pleural calcifications are not uncommon. Bilateral calcifications are almost always related to asbestos exposure. Unilateral calcifications are usually due to a previous infection or hemorrhage. In any case, when located in the anterior or posterior chest wall they are seen en face in the PA radiograph and may be confused with pulmonary infiltrates, as in the present case. Seen in profile in the lateral view they appear as a calcified line, and the diagnosis is then evident.

Sometimes, the calcified pleura are overlooked. In this particular case we have a useful marker that points our attention to the diseased pleura: the radiologic sign known as crow’s feet which represents subsegmental areas of peripheral fibrosis/atelectasis fixed by the fibrotic pleura. They are likely an early stage of rounded atelectasis. (Personally, I prefer the alternative term sun rays rather than crow’s feet. As a frequent visitor to Minorca, I am more familiar with sun rays than with crows, let alone their feet).

To emphasize the deceitful appearance of pleural calcification, I am showing two more cases.


Radiographs belong to a 52-year-old asymptomatic woman. The PA radiograph shows what appears to be a poorly-defined pulmonary infiltrate in the left lung (A, arrow). The lateral view shows two calcified pleural plaques: the posterior one is depicted as a calcified line (B, white arrow), whereas the anterior one is more oblique and simulates a rounded opacity (B, red arrow).

Sagittal CT clearly shows the anterior (C, arrow) and posterior plaques (D, arrow). No pulmonary infiltrates were seen in the lung view (not shown).


Preoperative PA chest radiograph in a 57-year-old man. There are several opacities in the left hemithorax that may be pulmonary infiltrates (A, white arrows) accompanied by left diaphragmatic and pleural calcifications (A, red arrows).

In the coronal CT (B) there are no lung abnormalities. Enhanced axial and sagittal CTs depict extensive pleural calcification (C and D, arrows). The apparent pulmonary infiltrates were due to pleural calcifications depicted en face. The patient had a history of TB in his youth.

Dr. Pepe’s teaching points:

1. Pleural disease can simulate pulmonary infiltrates.

2. Crow’s feet can direct our attention to overlooked pleural disease

12 thoughts on “Dr. Pepe Case 140 – Art of interpretation – SOLVED!

  1. Frontal radiograph there is bilateral hikar prominent vascular making more on the right hilum, prominent translucency over the right lower zone and right pleural effusion.
    There is abnormal linear shadow on the left hilum.
    Lateral radiograph there is prominent shadowing anterior to hilum which suggested of enlarged right pulmonary artery, right plural effusion.
    I think it is right pumonary embolism, and because of that shadow over the left hilum, possibly left PE too.

  2. PA chest: blunting of right lateral costophrenic angle, pleural thickening in the right apex, double right diaphragmatic contour. There are disorganized and coarsened interstitial markings with peribronchial cuffing, more prominent on the right with possible tubular bronchiectasis. There is a subtle hyperlucency of right upper lung zone and a hazy opacity in the right middle perihilar area, however the hilum remains visible.

    Lateral: the opacity is posterior (mostly 6th segment, with some extension into the 10th/2nd) and associated with the pleura, possibly even originating from it, while the pleura itself is thickened and with surrounding radiating strands of fibrotic tissue.
    The trachea is slightly deviated to the left and anteriorly, due to rotation, with a lucency seen adjacent to it, which might be due to slight overexpansion of right upper lobe due to emphysematous changes.

    Overall the clinical picture and evelated D dimers are strongly suggestive of PE and since any CXR abnormality might be associated with PE, a CT PE protocol should probably be performed.
    However right lung findings could also be due to chronic changes, like an inflammatory infiltrate during its resorption phase, COPD and some process involving the pleura.

  3. Emphysema, right lung perihiliar opacity, abnormal posterior heart contour. I’ve got a crazy idea: myocardial infarction with acute mitral regurgitation. Still I do believe troponin should be done earlier and infarction should be excluded prior to chest x-ray, so I’m probably wrong…

  4. cylindrical bronchiectatic changes in both lungs , mainly in central and bilateral lower lobes. few of dilated bronchi show air fluid level suggesting superinfection. both lungs show changes of chronic bronchitis with right lower lobe appearing more hyperluscent with flattening of hemidiaphragm ,probably bulla in lower lobe.
    ill-defined opacities with obscured margins in right para hilar location suggesting consolidation.
    summary chronic bronchitis with bronchiectatic changes with consolidation in right parahilar region.

  5. Good morning!! There are chronic pulmonary changes (emphisematous thorax with right lower inferior bullae). There is an increased density in the RLL (infectious process?)

  6. Since we are in Holy Week, I will give you a tip. There is a negative finding: the pulmonary infiltrate in the PA radiograph is not visible in the lateral view. Why?

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