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

Medical Image of the Week: Finger in Glove

Figure 1. PA (Panel A) and lateral (Panel B) chest x-ray showing finger in glove (arrow) in the right upper lung with other scattered areas of consolidation.

Figure 2. Repeat chest x-ray about a month later showing generalized clearing.

A 45-year old man with a history of asthma presented with increasing shortness of breath, and cough productive of dark firm plugs, sometimes branching. His chest x-ray (Figure 1) shows finger in glove (arrow) in the right upper lung with other scattered areas of consolidation. His serum IgE was elevated at 750 IU/ml (normal < 380 IU/ml).  His eosinophil count was 12%.   Aspergillus IgE was 6.69 (normal< 0.35). A diagnosis of probable allergic bronchopulmonary aspergillosis (ABPA) was made. He was given oral corticosteroids. Follow up about a month later showed dramatic clinical improvement and a repeat chest x-ray (Figure 2) showed generalized clearing.

The initial chest x-ray shows a “finger in glove” pattern in the right upper lobe (Figure 1, arrow), which is due to mucoid impaction within the larger bronchi (1). The same appearance has also been referred to as the rabbit ear appearance, Mickey Mouse appearance, toothpaste-shaped opacities, Y-shaped opacities, V-shaped opacities and the Churchill sign because it resembles the “V” gesture often associated with Winston Churchill.

ABPA is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus fumigatus, manifesting with poorly controlled asthma, recurrent pulmonary infiltrates and central bronchiectasis (2). Primary therapy consists of oral corticosteroids to control exacerbations, itraconazole as a steroid-sparing agent and optimized asthma therapy. Uncertainties surround the prevention and management of bronchiectasis, chronic pulmonary aspergillosis and aspergilloma as complications, concurrent rhinosinusitis, environmental control and long-term management.

Gerald F. Schwartzberg, MD

Phoenix, AZ

References

1. Weerakkody Y, Jones J. Finger in glove sign. Available at: http://radiopaedia.org/articles/finger-in-glove-sign (accessed 11/22/13).
2. Agarwal R, Chakrabarti A, Shah A, Gupta D, Meis JF, Guleria R, Moss R, Denning DW; ABPA complicating asthma ISHAM working group. Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria. Clin Exp Allergy. 2013;43(8):850-73. [CrossRef] [PubMed]

Reference as: Schwartzberg GF. Medical image of the week: finger in glove. Southwest J Pulm Crit Care. 2014:8(1):64-5. doi: http://dx.doi.org/10.13175/swjpcc169-13 PDF