A 28-year-old female with diabetes, chronic pancreatitis, and substance abuse presented with cough, chills, and nausea for 3 days. Imaging showed complete white-out of the left lung with an air bronchogram sign. The differential diagnosis for hemithorax white-out included pulmonary edema, consolidation, or a chest wall/pleural mass. Given the trachea was midline and presence of an air bronchogram sign, consolidation from pneumonia was suspected. The patient was treated with antibiotics.
2. Case
HPI: 28yo female with a history of poorly controlled type 1 diabetes,
chronic pancreatitis, and substance abuse presents to the ED with a 3 day
history of productive cough, chills, and nausea/vomiting. She was recently
discharged from the hospital 1 week ago following an episode of syncope
and hypoglycemia. She reported feeling “sick” the first few days following
discharge, but this feeling progressed to her current symptoms. During
first night of hospital stay patient had hematemesis with possible
aspiration
3. Case continued
PMH: Type 1 diabetes, chronic pancreatitis, substance abuse
Allergies: Ciprofloxacin, Levaquin
Meds: Lantus, pantoprazole, pregabalin, valacyclovir, zofran
Surgical Hx: Sinus surgery 2012, facial reconstruction 2007, c-section 2007,
I&D of deep abscess in soft tissue of neck
FH: Noncontributory
SH: Methamphetamine and opioid use. Smoker ½ ppd x 5 years
4. Case continued: Physical Exam
Vitals:
T: 39.4 C
HR: 137
RR: 22
BP: 93/47
SpO2: 100%
General: NAD
CV: Increased rate and regular rhythm, no murmurs, gallops, or rubs
Resp: Tachypnic, coarse breath sounds throughout, no wheezes rhonchi or
crackles
Remainder of exam is unremarkable
5. Imaging:
• Complete white-out of
left lung with air
bronchogram sign.
• Silhouetting of left heart
border and left hemi-
diaphragm
• Patchy ground glass
opacities in right lung
6. Differential Diagnosis: Hemithorax
white-out
Can be narrowed down based on location of trachea
Trachea pulled toward opacified side
Pneumonectomy
Total lung collapse
Pulmonary agenesis/hypoplasia
Trachea in mid-line position
Consolidation
Pulmonary edema/ARDS
Mass (pleural or chest wall)
Trachea pushed away from opacified side
Pleural effusion
Diaphragmatic hernia
Pulmonary mass
7. Case courtesy of A.Prof Frank Gaillard,
Radiopaedia.org, rID: 35971
Trachea pulled towards opacity:
Collapsed lung
8. Case courtesy of Dr Roberto
Schubert, Radiopaedia.org, rID:
16075
Trachea pushed away from opacity:
Pleural effusion
9. Trachea in mid-line position ddx:
Pulmonary edema/ARDS
Mass (pleural or chest wall)
Consolidation
10. Pulmonary edema
Pulmonary edema is caused by excess fluid in the lungs
Causes of unilateral pulmonary edema:
Re-expansion pulmonary edema
Unilateral emphysema
Unilateral pulmonary embolism
Positioning
Radiological findings: Vary
Upper lobe vessel cephalization and increased cardiac size (cardiogenic cause)
Peri-bronchial cuffing and Kerley B lines (interstitial edema)
Batwing airspace opacification and air bronchogram sign (alveolar edema)
11. Unilateral re-expansion pulmonary edema Air bronchogram sign in unilateral
pulmonary edema secondary to
aspiration while laying on right side
12. Upper lobe pulmonary venous
diversion Kerley B lines which
represent interlobular
septa
13. Chest wall or pleural mass
If large enough, masses can cause hemithorax white-out
Pleural mass – mesothelioma
Chest wall mass – Ewing’s sarcoma
Radiological findings:
Vary by cause, can be nonspecific
Can potentially displace adjacent structures
Can cause rib destruction
14. Ewing’s sarcoma of chest wall
Case courtesy of Dr Ahmed Almuslim,
Radiopaedia.org, rID: 6918
Mesothelioma
Case courtesy of Frank Gaillard, Radiopaedia.org,
rID: 8705
15. Consolidation
Consolidation is when the alveoli fill with dense material that causes
increased attenuation of x-rays
Causes:
Water
Blood
Pus
Protein
Radiological findings:
Lung opacification
Air bronchogram sign – air filled bronchi are visible due to the opacification of
surrounding alveoli
16. Our patient
Trachea midline
Air bronchogram sign
No rib crowding
Clinical history and exam
Productive cough
Potential aspiration
Hospitalized recently
Febrile
Diagnosis: Pneumonia
Treatment: Vancomycin, Zosyn,
Micafungin
17. References
Kagele, Steven F., and Nirmal B. Charan. “Unilateral Pulmonary
Edema.” Chest, vol. 102, no. 4, 1992, pp. 1279–1280.,
doi:10.1378/chest.102.4.1279.
Mullan, Charles P., et al. “Radiology of Chest Wall Masses.” American
Journal of Roentgenology, vol. 197, no. 3, 2011, doi:10.2214/ajr.10.7259.
https://radiopaedia.org/articles/hemithorax-white-out-differential
https://radiopaedia.org/articles/air-bronchogram