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A 36-year-old man presented to the ED complaining of a cough. He had been drinking heavily that night and did not have a place to stay.

On arrival in the ED, he was ill-kempt and lethargic, but arousable. His vital signs were normal: blood pressure 120/80 mm Hg, pulse 88 beats/min, respiratory rate 18 breaths/min, and temperature 98.8°F. His oxygen saturation was 97% on room air and finger stick blood glucose was 110 mg/dL. There was a laceration on his forehead that had been sutured two weeks ago, but no evident acute trauma. Because he had a cough that was productive of blood-tinged sputum, he was triaged to a respiratory isolation room. He stated that he had never had tuberculosis (TB), but a PPD tuberculin skin test had been positive in the past.

He was seen by a physician one hour later, at which time he was more alert. He stated that he had been assaulted with a stick two weeks previously and needed to have the sutures on his forehead removed. He also described a cough for about one week and shortness of breath when walking up stairs. He had similar symptoms several months earlier and had been prescribed medications that he was no longer taking. On examination, heart sounds were normal, and lungs were clear to auscultation.

For the past two months, he had been staying in a nearby homeless shelter or occasionally with a friend or on the street. He had had an HIV test in the past but did not know the result.

Chest radiographs were obtained (Figure 1).

  • What do they show?

The major diagnostic concern in this patient, given his symptoms (cough and hemoptysis), history of a positive PPD skin test, and his social situation (alcoholism and homelessness), was tuberculosis (TB). With reactivation TB, the expected radiographic findings are an upper lobe infiltrate with cavitation and scarring. Alternatively, if the patient had primary TB or was immunocompromised, there could be segmental consolidation, hilar adenopathy, or a miliary pattern.

This case illustrates two problematic aspects of chest radiograph interpretation problematic—the hila and lung markings. There is great variation in the normal appearance of these structures, and detecting abnormalities can therefore be difficult.

Hilar Enlargement

In this patient, although the hila are prominent, they have a branching vascular appearance, not the “lumpy” appearance, characteristic of lymph node enlargement (Figure 2). In addition, the upper portions of the hila are enlarged relative to the lower portions. This is due to pulmonary venous hypertension, which causes dilation of the superior pulmonary veins. The enlarged superior ...

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