February 2014 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 60-year-old man presented with a history of weight loss and dysphagia for about 2 weeks duration. There was a possible history of asthma accompanied by ongoing shortness of breath first noticed nearly 2 years ago. Frontal chest radiography (Figure 1) was performed.

Figure 1.  Frontal chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Choose the correct answer to move to the next panel)

1. The chest radiograph shows a mass
2. The chest radiograph shows hilar and mediastinal lymph node enlargement
3. The chest radiograph shows multifocal consolidation
4. The chest radiograph shows multifocal, somewhat basal predominant linear opacities suggesting fibrosis
5. The chest radiograph shows multiple nodules

Reference as: Gotway MB. February 2014 imaging case of the month. Southwest J Pulm Crit Care. 2014;8(2):88-95. doi: http://dx.doi.org/10.13175/swjpcc010-14 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