Medical Image of the Month: Hampton Hump and Palla Sign

Figure 1. A chest radiograph demonstrates a wedge-shaped opacity in the right lung base (red circle) and enlargement of the right descending pulmonary artery branch (blue arrow) consistent with a Hampton hump and Palla sign, respectively.

Figure 2. A computed tomography angiogram (CTA) of the chest in a lung window demonstrates a wedge-shaped opacity in the right middle lobe consistent with a Hampton hump (red circle).

Figure 3. A CTA of the chest demonstrates an embolus in the right main pulmonary artery which appears slightly dilated (red circle).

Figure 4. A CTA of the chest demonstrates extension of the pulmonary embolus into the right lower lobe pulmonary arterial branch (blue circle) along with a right middle lobe pulmonary infarction (red circle) which is better demonstrated in Figure 2.

A 51-year-old lady presented to emergency room with acute, severe, right-sided pleuritic chest pain, mild cough and dyspnea at rest. She underwent a lumbar spine laminotomy and foraminotomy twelve days prior to her presentation with limited mobility after her operation. On examination, she was tachypneic and tachycardic. Her blood pressure and oxygen saturations on room air were normal. Chest auscultation revealed a few crackles in the right lung base. There was no pedal edema or calf tenderness.

A chest radiograph demonstrated a right lower lobe wedge-shaped opacity along with right hilar prominence (Figure 1). She was initially diagnosed with a right lower lobe pneumonia and was admitted to step-down unit for further management. However, her history, clinical examination, and chest radiograph findings suggested the high likelihood a pulmonary embolism. A computed tomography angiogram (CTA) of the chest confirmed the diagnosis of a pulmonary embolism (Figures 2-4).

Based her clinical presentation and radiology results, the patient was diagnosed with a sub-massive pulmonary embolism (PE). She was treated with an intravenous heparin drip. She was hemodynamically stable throughout the hospital admission. Her echocardiogram showed no evidence of right ventricular strain. Eventually, she was transitioned to oral anticoagulation and was discharged home in good condition.

Discussion

The wedge-shaped right lower lobe opacity and right hilar prominence correspond to a Hampton hump and Palla sign, respectively. A Hampton hump represents a pulmonary infarction secondary to PE, and it was named by the radiologist Aubrey Hampton in 1940 (1). The Palla sign is an enlarged right descending pulmonary artery, an observation made in 1983 by a radiologist, Antonio Palla (2). Both signs can be seen on chest radiography and may aid in the diagnosis of a PE.

Although these radiologic findings of PE are rare, practicing physicians should be aware of these findings as they can be extremely helpful and expediate the diagnosis of a PE. On the other hand, misinterpretation of these findings can lead to a delay in the diagnosis of other significant chest pathologies.

Abdulmonam Ali MD and Naga S Sirikonda MD

SSM Health

Mount Vernon, IL USA

References

1. Hampton AO, Castleman B. Correlation of postmortem chest teleroentgenograms with autopsy findings with special reference to pulmonary embolism and infarction. Am J Roentgenol. 1940;43:305–26.
2. Palla A, Donnamaria V, Petruzzelli S, Rossi G, Riccetti G, Giuntini C. Enlargement of the right descending pulmonary artery in pulmonary embolism. AJR Am J Roentgenol. 1983;141:513-7. [CrossRef] [PubMed]

Cite as: Ali A, Sirikonda NS. Medical image of the month: Hampton hump and Palla sign. Southwest J Pulm Crit Care. 2019;19(5):144-5. doi: https://doi.org/10.13175/swjpcc041-19 PDF

Medical Image of the Week: Oligemic Lung Field

A Sinister Sign of Acute Pulmonary Embolism? 

Figure 1. Panel A: The chest x-ray showed decreased vascular markings in the right lung field (oligemic right lung field) and reduced prominence of right pulmonary artery.  There is also a small opacity in right lower lung field possibly a pulmonary infarct. Panel B: A Coronal section of the computed tomographic pulmonary angiography showing a large thrombus in the right pulmonary artery (white arrow). Panel C: A 12-lead EKG shows sinus tachycardia, right bundle branch block, deep S wave in lead I (black arrow), deep q wave (orange arrow) and inverted T-wave (green arrow) in lead III. Panel D: A computed tomographic pulmonary angiography showing an enlarged right ventricle (blue arrow) compressing the left ventricle (red arrow).

A 67 year-old woman presented with pleuritic, non-radiating chest pain of sudden onset. She was anxious, diaphoretic, and tachycardic.

The chest radiograph (Figure 1A) showed decreased vascular markings in the entire right lung field (oligemic right lung field) and reduced prominence of the right pulmonary artery.  A small opacity in right lower lung field was suspicious for a pulmonary infarct. A follow-up computed tomographic pulmonary angiography (CTA) showed a large embolus in right pulmonary artery and a smaller embolus in the subsegmental left pulmonary artery (Figure 1B). Twelve-lead electrocardiogram (EKG) findings were notable for a new onset right bundle branch pattern, deep S wave in lead I, with a q-wave and inverted T-wave in Lead III (Figure 1C). A 2-Dimentional echocardiogram showed a massively dilated and hypokinetic right ventricle. The CTA also revealed that the massively distended right ventricle with a deviated interventricular septum was compressing the left ventricle (Figure 1D). Venous duplex study of lower extremities showed an acute thrombosis of the right popliteal vein. 

The patient showed marked clinical improvement after the infusion of tissue plasminogen activator (tPA) and heparin. A chest x-ray obtained 2 days later showed resolution of right sided oligemia. On Day 6, the right bundle branch block had resolved.

Radiographic findings in acute pulmonary embolism (PE) are uncommon. The Westermark sign (oligemia), Hampton hump and prominent central pulmonary artery are infrequently seen in acute PE. Westermark sign of an entire side lung field is rare, sinister sign of a large burden pulmonary embolism.  If identified early, this sign can be invaluable in early recognition and management.

Suman B. Thapamagar MBBS, Ramya Mallareddy MD, Ilya Lantsberg MD

Easton Hospital, Drexel University, Department of Internal Medicine, 250 S. 21st Street, Easton, PA 18042

Reference

1. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363(3):266-74. [CrossRef] [PubMed]

Reference as: Thapamagar SB, Mallareddy R, Lantsberg I. Medical image of the week: oligemic lung field. Southwest J Pulm Crit Care. 2014:8(1):48-9. doi: http://dx.doi.org/10.13175/swjpcc163-13 PDF