Dear Friends,
Presenting today radiographs of an 89-year-old woman with dyspnea and moderate fever.
Diagnosis:
1. Empyema
2. Mediastinal tumor
3. Pneumonia
4. None of the above
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Findings: PA chest radiograph shows an opacity occupying the middle and lower right lung It is located anteriorly in the lateral view and has a well-defined posterior border.
The clue to the diagnosis lies with the bubbles of air within the opacity (A, red arrows) which resemble bowel loops in the lateral view (B, circle). The heart is displaced towards the left, but this finding cannot be evaluated because of the moderate scoliosis. In addition, a hiatus hernia is present (A-B, arrows).
Enhanced axial CT (C-D) demonstrates that the opacity consists mainly of fat containing some bowel loops.
Coronal and sagittal reconstructions show a large gap in the anterior right hemidiaphragm (E-F, circles), with herniation of bowel and abdominal fat into the hemithorax.
Final diagnosis: large Morgagni´s hernia simulating pulmonary disease.
Congratulations to xristoby, who was the only one who mentioned anterior diaphragmatic hernia.
Teaching point: Remember that any lower lung lesion adjacent to the diaphragm may arise from the abdomen, as demonstrated with the present case.
….Ernia iatale da scivolamento gastrico con polmonite da aspirazione.
Features of achalazia
Opacification of the right hemithorax involving the bus and lower zones giving wedge shape like area on lateral chest view
Which could be collapse / consolidation
Good morning!!!
There is an increased density projected over the medium lobe with aereal opacities. Cardiac is displaced to the left and I can´t see its right border probable because of the hiatal hernia. I suggested pneumonia
You can not evaluate the heart position because the patient has scoliosis. However, it is a good observation. Follow it.
Achalasia cardia with aspiration pneumonia of the right mid and lower zones.
The upper esophagus is not dilated in the lateral view, which goes against achalasia
Hernia showing fluid level with possible aspiration pneumonia.
The opacity is anterior, which is unusual for aspiration pneumonia.
There isn´t loss of volume so probably the patient has a pleural effussion with air bubbles (empyema)
Keep trying 🙂
Any relevant personal history as TBC?
No
Hiatal hernia sir
What about the opacity in the right hemithorax?
1- hiatal hernia
2-right anterior mediastinal mass, with water density and water-air levels.
What about the opacity in the right hemithorax?
The opacity in right hemitorax has c fluid-air levels . It can be in association with neumonía, pulmonary sequestration, congenital pulmonary airway malformation, anterior diafragmatic hernia
Which one will you choose, considering the X-ray findings?
It depends on the age, with 89 years, first I choose a diafragmatic hernia, the second one would choose a lung malformation.
NECROTISING PNEUMONIA
Congenital hernia with abdominal organs in the chest