What should be included in the note to radiology when ordering a chest x-ray for a patient with a history of fungal lung infection, partial right lung resection for lung cancer, and incomplete treatment, who presents with expiratory congestion but denies symptoms such as shortness of breath, cough, or chest pain?

Radiology Note for Chest X-Ray in Patient with History of Fungal Lung Infection and Lung Resection

Order a two-view chest X-ray (PA and lateral) with the following clinical indication: "History of pulmonary fungal infection with incomplete treatment, prior partial right lung resection for malignancy, presenting with expiratory congestion on exam. Evaluate for chronic pulmonary aspergillosis, aspergilloma, recurrent fungal infection, post-surgical changes, and exclude malignancy."

Essential Clinical Information to Include

Your radiology note should contain these specific elements to ensure appropriate interpretation and potential need for advanced imaging:

Primary Clinical Details

• History of fungal lung infection (specify organism if known) with incomplete treatment course due to insurance coverage loss 1
• Prior partial right lung resection for lung cancer (specify location and date if available) 1
• Current exam finding: expiratory congestion raising concern for chronic pulmonary aspergillosis 1
• Absence of acute symptoms: denies shortness of breath, cough, chest pain, or hemoptysis 1

Critical Context for Radiologist

Include these high-risk factors that increase suspicion for serious pathology:

• Post-surgical cavity or structural changes create substrate for aspergilloma formation, which appears as a solid rounded mass within a cavity separated by an airspace (the classic "air crescent sign" is a delayed finding) 1, 2
• Incomplete antifungal treatment increases risk of chronic necrotizing aspergillosis or progression to invasive disease 1
• History of lung cancer means any new nodule, mass, or consolidation could represent recurrence, metastasis, OR fungal infection mimicking malignancy 3, 4, 5, 6

Why Chest X-Ray May Be Insufficient

Be prepared that chest X-ray has significant limitations in this clinical scenario:

• Chest radiography has low sensitivity (69-71%) for detecting pulmonary abnormalities compared to CT, particularly for early fungal infections, small nodules, and subtle interstitial changes 1
• In immunocompromised or high-risk patients, approximately 50% have pathological findings on CT when chest X-rays appear normal 2
• Fungal infections mimicking malignancy are frequently missed on plain films, with 2 out of 266 patients in one series having malignancy despite normal chest X-rays 1

Specific Findings to Request Radiologist Evaluate

Direct the radiologist to specifically comment on:

• Post-surgical changes in the right hemithorax and any new or enlarging cavitary lesions 1
• Aspergilloma features: solid rounded mass within cavity, mobile or fixed, with surrounding airspace 1
• Consolidation, nodules, or masses that could represent fungal infection OR malignancy recurrence 2, 3, 6
• Pleural thickening adjacent to any cavitary lesions (characteristic of aspergilloma) 1
• Comparison with prior imaging if available, as subtle interval changes are critical for detecting early infection or recurrence 2

Plan for CT Chest if X-Ray is Normal or Equivocal

Given this patient's high-risk profile, strongly consider proceeding directly to CT chest with IV contrast instead of or in addition to chest X-ray:

• CT has 79% sensitivity and 85% specificity for invasive pulmonary aspergillosis in high-risk patients 2
• The American College of Radiology and multiple pulmonary societies recommend CT for patients with chronic lung disease, prior malignancy, and concern for fungal infection even when chest X-rays are normal 1, 2
• CT is superior for detecting: early halo sign, air-crescent sign, cavitation, bronchiectasis, and distinguishing fungal infection from malignancy 1, 2, 7
• In patients with history of lung cancer, fungal infections frequently mimic tumor recurrence on imaging, and CT provides better characterization 5, 6

Critical Pitfall to Avoid

The most dangerous error is assuming a normal chest X-ray excludes significant pathology in this patient. With incomplete fungal treatment, prior lung resection creating potential cavities, and history of malignancy, this patient has multiple risk factors for life-threatening complications including massive hemoptysis from aspergilloma (fatal in up to 26% of cases) or invasive aspergillosis 1. Document that if chest X-ray is normal but clinical suspicion remains, CT chest should be obtained rather than adopting a "wait and see" approach 1, 2.