Underinspiration and poor positioning mimicking lung pathology in a pediatric patient
Presentation
Increased work of breathing, inspiratory stridor, fever, and COVID exposure 4-5 days prior.
Patient Data
Initial chest x-ray
Initial semi-erect chest x-ray imaging demonstrates significant diffuse airspace opacities overlying the cardiomediastinum and lungs. Some of these opacities have a consolidative appearance, particularly in the retrocardiac region.
Chest x-ray 1 hour later
Follow-up upright imaging with full inspiration reveals clear lung and retrocardiac spaces with mild peribronchial cuffing, no wide-spread or consolidative airspace disease is appreciated.
Case Discussion
Pediatric chest x-ray positioning can be difficult with infants or toddlers. Positioning may require positioning devices. Upright imaging is important to avoid lordotic artifacts, including artifacts that may look like diffuse or consolidative airspace disease. In particular, the thymus of pediatric patients is often enlarged and may result, in cases of lordosis and hypoinflation, as airspace disease.
In this case, repeat imaging in a more upright position with improved inspiration resulted in resolution of the artifact and atelectasis seen on the initial semi-erect/lordotic imaging. The x-ray did reveal mild peribronchial cuffing, which has been reported to be the most common finding of pediatric patients with COVID infection. The patient did have an acute COVID infection and croup, and he recovered following steroid and nebulizer treatments.
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