SET T0028 -
Emergency Department -
Chest Radiographs

Abnormal. An apical pneumothorax is present on the right side.

Diagnosis: Spontaneous Pneumothorax.

Note: the difference between the apices of the right and left lungs. Specifically (1) the visceral pleural line is just visible at the right apex, and (2) the absence of any lung markings lateral to this visceral pleural line.

In this patient - the pleural line is somewhat irregular in appearance (probably because of pleural blebs), and the most obvious feature on scrutinising this CXR is the difference in blackness (ie due to lack of vessels) at the right lung apex as compared with the left lung apex. See : The Chest X-Ray : A Survival Guide : Pages 94-96

Fracture of the medial aspect of the right clavicle.

The ribs and other bones appear intact.

Lungs clear.

Comment: most clavicle fractures are easy to suspect, and to detect, on clinical examination. Occasionally, as in this case, when a patient is unable to pinpoint the precise site of the pain it is the careful scrutiny of the lungs and all of the bones on the CXR that allows the correct diagnosis to be made. A few useful notes on clavicle fractures (ie frequency and sites) . . .  See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Page 81

The paratracheal appearances are not anatomical - ie they are abnormal.

Initially, one might suspect right paratracheal lymphadenopathy - and that needs to be a consideration. But further evaluation of the CXR indicates that the left paratracheal region is also abnormal because there is increased shadowing in this area or overlying this area. We need to ask ourselves - is this shadowing truly paratracheal? Could it be further posterior in position? In other words - could the shadowing represent displacement of the right and left paravertebral stripes by a parvertebral mass? In this patient, young and with a high fever, spinal tuberculosis would then be a consideration.

Eventual diagnosis: T3/T4 paraspinal mass; TB.

Comment (1). You are at a disadvantage without a windowing facility on this Test Yourself site. Nevertheless, the crucial observation to make is that there is abnormal shadowing projected to the right and left sides of the trachea on this CXR. That allows several possible sites for the origin of this abnormal shadowing to be considered. Did you consider a posterior position (ie paravertebral) to be a possibility?

Comment (2). Are you familiar with the paravertebral stripes? Understanding their normal and abnormal appearances can be very useful when assessing frontal view CXRs . . .   See : The Chest X-Ray : A Survival Guide : Pages 112-115

Observations:

1. Extensive free intraperitoneal air .  .  . air under the right hemi-diaphragm and also outlining loops of bowel on the left side of the abdomen.

2. Extensive surgical emphysema in the neck and axillae.

3. Left sided pneumothorax.

Likely cause?

Note the history - ie no trauma, no surgery, & no earlier intervention by a physician (ie this patient had not been treated in ITU).

Occasionally, some domes of the diaphragm are leaky - with defects or fenestrations . . . these defects may allow communication between the peritoneal space with the mediastinum and/or with a pleural space.

Given the clinical history, and with the massive amount of intraperitoneal air that is evident, then the strong possibility is a perforated viscus and a " leaky " dome of the diaphragm has allowed air to enter the mediastinum. The air then tracks up into the neck. In addition, the peritoneal cavity communicates - in this patient - with the left pleural space and thus a left sided pneumothorax has resulted.

Follow Up: CT demonstrated colonic diverticulitis and a perforation of the sigmoid colon.

Comment: Leaky dome/domes of the diaphragm are periodically referred to in the literature and usually in the context of patients with ascites who develop an unexpected pleural effusion (in the absence of primary pulmonary or pleural pathology). These cases are intriguing. In another group of patients, the cause of a pneumothorax occurring in young women at the time of menstruation is uncertain and speculative - but a leaky diaphragm has been offerred as one possibility (see Catamenial pneumothorax).