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History: An 83 year old man with previous coronary artery bypass surgery and multiple percutaneous coronary interventions, now presented with labored breathing. Chest X-ray is shown in the above image. What is your diagnosis?

a) Tuberculosis

b) Myocardial infarction

c) Congestive heart failure

d) Lung abscess

Ans: c) Congestive heart failure The above X-ray image shows, Kerley-B lines (pointed by arrows), with cardiomegaly, dilated pulmonary vessels, fluid in right horizontal fissure, all suggestive of congestive heart failure.

The Kerley B lines are multiple, thin, short, white lines which are perpendicular to the chest wall at the lung base which represents fluid which has leaked into the interlobular septae. It is one of the signs of congestive heart failure.

Kerley B lines are seen in: Pulmonary edema Lymphangitis carcinomatosa and malignant lymphoma Viral and mycoplasmal pneumonia • Interstitial pulmonary fibrosis Pneumoconiosis Sarcoidosis

Other Kerley lines: Kerley A lines: These are long unbranching lines coursing diagonally from the hila out to the periphery of the lungs. They are caused by distension of anastomotic channels between peripheral and central lymphatics of the lungs. Kerley C lines: They are short, fine lines throughout the lungs, with a reticular appearance. They may represent thickening of anastomotic lymphatics or superimposition of many Kerley B lines.

In general, based on how commonly they appear, in chest X-rays, Kerley B (most common) > A > C (least common)

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