Background/Objectives: The clinical adoption of AI in radiology requires models that balance high accuracy with interpretable, anatomically plausible reasoning. This study presents an integrated diagnostic framework that addresses this need by unifying a hybrid deep-learning architecture with explicit anatomical guidance and neuro-symbolic inference. Methods: The proposed system employs a dual-path model: an enhanced EfficientNetV2 backbone extracts hierarchical local features, whereas a refined Vision Transformer captures global contextual dependencies across the thoracic cavity. These representations are fused and critically disciplined through auxiliary segmentation supervision using CheXmask. This anchors the learned features to lung and cardiac anatomy, reducing reliance on spurious artifacts. This anatomical basis is fundamental to the interpretability pipeline. It confines Gradient-weighted Class Activation Mapping (Grad-CAM) visual explanations to clinically valid regions. Then, a novel neuro-symbolic reasoning layer is introduced. Using a fuzzy logic engine and radiological ontology, this module translates anatomically aligned neural activations into structured, human-readable diagnostic statements that explicitly articulate the model’s clinical rationale. Results: Evaluated on the NIH ChestX-ray14 dataset, the framework achieved a macro-AUROC of 0.9056 and a macro-accuracy of 93.9% across 14 pathologies, with outstanding performance on emphysema (0.9694), hernia (0.9711), and cardiomegaly (0.9589). The model’s generalizability was confirmed through external validation on the CheXpert dataset, yielding a macro-AUROC of 0.85. Conclusions: This study demonstrates a cohesive path toward clinically transparent and trustworthy AI by seamlessly integrating data-driven learning with anatomical knowledge and symbolic reasoning.

Background: Chest X-ray (CXR) is widely used for the assessment of thoracic diseases, yet automated multi-label interpretation remains challenging due to subtle visual patterns, overlapping anatomical structures, and frequent co-occurrence of abnormalities. While recent deep learning models have shown strong performance, limitations in interpretability, anatomical awareness, and robustness continue to hinder their clinical adoption. Methods: The proposed framework employs a hybrid ConvNeXtV2–Vision Transformer (ViT) architecture that combines convolutional feature extraction for capturing fine-grained local patterns with transformer-based global reasoning to model long-range contextual dependencies. The model is trained exclusively using image-level annotations. In addition to classification, three complementary post hoc components are integrated to enhance model trust and interpretability. A segmentation-aware Gradient-weighted class activation mapping (Grad-CAM) module leverages CheXmask lung and heart segmentations to highlight anatomically relevant regions and quantify predictive evidence inside and outside the lungs. An ontology-driven neuro-symbolic reasoning layer translates Grad-CAM activations into structured, rule-based explanations aligned with clinical concepts such as “basal effusion” and “enlarged cardiac silhouette”. Furthermore, a lightweight out-of-distribution (OOD) detection module based on confidence scores, energy scores, and Mahalanobis distance scores is employed to identify inputs that deviate from the training distribution. Results: On the VinBigData test set, the model achieved a macro-AUROC of 0.9525 and a Micro AUROC of 0.9777 when trained solely with image-level annotations. External evaluation further demonstrated strong generalisation, yielding macro-AUROC scores of 0.9106 on NIH ChestXray14 and 0.8487 on CheXpert (frontal views). Both Grad-CAM visualisations and ontology-based reasoning remained coherent on unseen data, while the OOD module successfully flagged non-thoracic images. Conclusions: Overall, the proposed approach demonstrates that hybrid convolutional neural network (CNN)–vision transformer (ViT) architectures, combined with anatomy-aware explainability and symbolic reasoning, can support automated chest X-ray diagnosis in a manner that is accurate, transparent, and safety-aware.

Pulmonary diseases rank among the leading causes of mortality worldwide, underscoring the importance of early detection to enhance patient outcomes and reduce fatalities. Chest X-rays (CXRs) serve as a critical diagnostic tool for identifying lung diseases; however, many pulmonary conditions exhibit similar patterns on CXRs, making differentiation challenging even for experienced radiologists. Furthermore, a single CXR may reveal multiple coexisting diseases, such as pneumonia and pleural effusion. Moreover, most existing studies in this field have been constrained to a limited number of classes and datasets, leaving significant gaps in the classification of diverse pulmonary conditions, particularly in remote regions where access to skilled radiologists is scarce. Recently, vision transformers (ViTs) have become a key technique in deep learning, and they have been widely used to detect different diseases from CXRs. This study aimed to adapt and optimize the pre-trained ViT-B16 model to predict and distinguish between single and dual pulmonary diseases whose diagnoses relied only on CXRs. The goal was to discriminate eight classes of evidence, which consisted of individual diseases (COVID-19, pneumonia, pneumothorax, tuberculosis, and pleural effusion), dual diseases (pneumonia and pleural effusion as well as pneumothorax and pleural effusion), and normal status. The experimental results show that the proposed model distinguished more classes than previous methods, with an accuracy of 98.18%. To the best of our knowledge, this is the first study to attempt to discriminate eight classes of evidence concerning pulmonary diseases, including both individual and dual diseases.