What’s the cause of this woman’s chest x-ray abnormality?
Vol.19, No.09, December 2011

A 38-year-old female presents with fever, chest pain and general malaise after recent surgery. She suffers from a mild cough without sputum production. Her past medical history is non-contributory.

What’s the most likely cause of this woman’s chest x-ray abnormality?

a) post-operative empyema with air-fluid levels

b) classic right lower lobe aspiration pneumonia

c) loculated right base pneumothorax

d) right breast abscess

e) classic Hampton’s hump from pulmonary embolus

f) classic Westermark sign from pulmonary embolus

ANSWER
Solution to Analyze This!

d) right breast abscess

The “recent surgery” was in fact placement of bilateral breast implants, and unfortunately the right implant region has become infected with development of a large right breast abscess. The abscess is evidenced by the multiple air-fluid levels in the right breast soft tissues.

To localize the abnormality accurately (as with any abnormality on two or more views) it’s important is use both chest x-ray projections. On the PA/frontal film (Fig. 1) careful inspection will reveal that some of the air-fluid levels extend laterally beyond the confines of the right rib cage, indicating that the infected collection could not reside within the thoracic cavity but rather outside of it (thus essentially ruling out all of the other diagnostic options provided). This assumption is further proven correct when viewing the lateral x-ray (Fig. 2), which shows the air-fluid levels present in the breast tissue region, anterior to the thoracic cavity.

A post-operative empyema (collection of pus in the pleural space) would have the air-fluid levels residing in the pleural space and as such would all be within the confines of the thoracic cavity. The same can be said for the other options presented as well, so I shall discuss them more for what they might normally present as on a chest x-ray. Aspiration pneumonia would reveal air space consolidation with or without air bronchograms, but air-fluid levels should not be present — that would signify a pulmonary abscess. A loculated right base pneumothorax would show increased lucency at the right base, with displacement of normal lung tissue, rather than the increased density in the present case. If a pneumothorax is present along with a pleural effusion, then air fluid levels can be visualized within the pleural space, without frank abscess formation.

The chest radiograph is a fundamental non-invasive test in the initial evaluation of patients suspected of having a pulmonary embolism (PE). The chest x-ray is not performed to actually diagnose the pulmonary embolism, but rather to rule out other thoracic diseases which might mimic PE including pneumonia, pneumothorax and congestive heart failure. Data that describe chest radiographic findings associated with the diagnosis of pulmonary embolism are limited, but prior to today’s more sophisticated imaging methods of diagnosing PEs (gold standard of enhanced CT pulmonary angiography, as well as the prior gold standard, the nuclear medicine V/Q or ventilation-perfusion test), chest x-ray was all there was. As such, a few very non-specific x-ray findings were described in association with PEs. The Hampton’s hump (named after Dr. Aubrey Hampton, who described it in 1940) describes a wedge-shaped pleural-based area of air-space consolidation, signifying localized pulmonary infarction. The Westermark sign refers to a localized area of pulmonary lucency, in keeping with regional oligemia (vasoconstriction) that appears distal to the site of a large pulmonary embolus.

 

References

1. Ray J. Can J Cardiol 2003;19:317

2. Worsley D. et al. Radiology 1993;189:133-6.

3. Hampton AO, Castleman B. Am J Roentgenol Radium Ther 1940;34:305-26.

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Figures 1&2: Shown is a chest x-ray exam with frontal (Figure 1) and lateral (Figure 2) projections. The abnormality involves the right side of the chest.
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