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
What do you see? Come back on Friday to see the answer!
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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.