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

November 2019 Imaging Case of the Month: A 56-Year-Old Woman with a Rash

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 56-year-old post-menopausal woman with a remote history of asthma and asymptomatic uterine fibroids presented with a macular-papular rash over the upper chest, upper medial left forearm, and medial legs, without scaling that has intermittently recurred over the previous few years. The rash is unaccompanied by fever, chills, rigors, abdominal pain, cough, conjunctivitis, urethritis, or any other mucocutaneous lesions. The patient did not note any seasonal relationships or association with food, and the rash regresses promptly with H₁ or H₂-blocker therapy.

The patient’s past medical history was otherwise unremarkable. Her surgical history was positive only for a laparoscopic left inguinal hernia repair 7 years earlier. The patient indicated she was neither a smoker nor a drinker. Her medications included an as-needed albuterol inhaler, a steroid inhaler, a nasal steroid spray, a multivitamin, and a topical steroid.

The patient’s physical examination showed normal vital signs, although her pulse rate was 95 beats / minute. The physical examination was otherwise entirely within normal limits aside from her presenting complaint of rash; in particular, her lungs were clear to auscultation. 

About 2 weeks later, the patient began to complain of myalgias and some wheezing in addition to her rash, with some mild fatigue as well. She denied other complaints, such as coryza, cough, nasal drainage, ear pain, and neck pain or stiffness. At repeat physical examination, her lungs remained clear to auscultation; no wheezing was noted. A dermatology consult suggested that the rash was most consistent with atopic dermatitis, for which a topical steroid was prescribed.

Basic laboratory data showed a white blood cell count in the normal range, mild anemia (hemoglobin / hematocrit = 11.5 mg/dL / 34.7%), a normal platelet count, normal serum chemistries and renal function parameters, and normal liver function tests aside from a mildly elevated alkaline phosphatase level of 145  U/L147 (normal, 35 – 104 U/L). A C-reactive protein level was elevated at 38.5 mg/L (normal, ≤8 mg/L). The patient was referred for chest radiography (Figure 1).

Figure 1.  Frontal chest radiograph.

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

1. The chest radiograph shows mediastinal and peribronchial lymph node enlargement
2. The chest radiograph shows bilateral consolidation
3. The chest radiograph shows cavitary lung disease
4. The chest radiograph shows findings suggesting increased pressure pulmonary edema
5. The chest radiograph shows numerous small nodules

Cite as: Gotway MB. November 2019 imaging case of the month: a 56-year-old woman with a rash. Southwest J Pulm Crit Care. 2019;19(5):127-43. doi: https://doi.org/10.13175/swjpcc065-19 PDF