September 2017 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA 

Clinical History: A 48-year-old woman with no previous medical history presented with complaints of intermittent cough persisting several months following a recent upper respiratory tract infection. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 98% on room air. Upon close inspection, the right thorax appeared slightly asymmetrically smaller than the left.

Laboratory evaluation was unremarkable. Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of nine pages)

1. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows large lung volumes
4. The chest radiograph shows multifocal consolidation and pleural effusion
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Gotway MB. September 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(3):104-13. doi: https://doi.org/10.13175/swjpcc109-17 PDF 

Medical Image of the Week: Unilateral Diaphragm Paralysis

Figure 1. CT scans showing unilateral diaphragm paralysis and atelectasis of right lower lobe (arrow).

An 85 year old woman with a history of COPD presented to the emergency department (ED) with shortness of breath and cyanosis of her fingers. Her symptoms have been waxing and waning since she recovered from pneumonia a year ago. A week prior to admission, she visited an outpatient clinic for worsening cough, which was treated with levofloxacin, however her shortness of breath and cyanosis persisted. O₂ saturation with 4 L oxygen was 85% and CT chest without contrast showed unilateral diaphragmatic paralysis with basilar atelectasis (Figure 1). She has no history of cardiac surgery, poliomyelitis or cervical spondylosis. Also, no cervical or lung mass was found on CT scan. Her diaphragmatic paralysis is most likely secondary to phrenic nerve injury.

Unilateral diaphragmatic paralysis is usually asymptomatic and does not require treatment in most of cases. However, patients with underlying lung disease can present with shortness of breath and cyanosis because of increased ventilatory demands on physical activity or superimposed pulmonary disease. Occasionally, patients with unilateral diaphragmatic paralysis can develop acute respiratory failure due to exacerbation of obstructive lung disease or respiratory infection, and require ventilatory support (1). Early and careful management of underlying lung disease is pivotal in these patients to prevent respiratory decompensation.

Seongseok Yun, MD PhD; Kahroba Jahan, MD; Natali Hua, DPM; Ibrahim Taweel, MD; Ismail Tabash, MD

Department of Medicine, University of Arizona, Tucson, AZ 85724, USA

Reference

Qureshi A. Diaphragm paralysis. Semin Respir Crit Care Med. 2009;30(3):315-20.  [CrossRef] [PubMed] 

Reference as: Yun S, Jahan K, Hua N, Taweel I, Tabash I. Medical image of the week: unilateral diaphragm paralysis. Southwest J Pulm Crit Care. 2014;8(1):68-9. doi: http://dx.doi.org/10.13175/swjpcc178-13 PDF