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ENDGAMES: A Gupta, D S Urquhart, A Devaraj, and I M Balfour-Lynn A 2 year old with fever and cough BMJ 2009; 339: b2150 [Full text]

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Errors in this case

Liam G Mcknight   (14 July 2009)

Response: Errors in this case

Atul Gupta, Anand Devaraj, Donald S Urquhart, Ian M Balfour-Lynn   (1 August 2009)

Errors in this case 14 July 2009
Liam G Mcknight, consultant radiologist Morriston hospital, Swansea, SA6 6NL Send response to journal: Re: Errors in this case	The authors state "The chest radiograph shows near complete opacification of the right hemithorax, with preservation of lung volumes and absence of air bronchograms". There are important errors in their observations. The radiograph shows collapse and consolidation in the right lung. There is a pleural effusion and there is not preservation of lung volumes. Their correct observation that the mediastinum is central shows that there must be loss of volume in the lung as there is a pleural effusion. If the lung volume is preserved and a pleural effusion is present then the mediastinum shifts away from the abnormality. If the lung collapses and there is no pleural effusion then the mediastinum shifts towards the abnormality. When the mediastimun is central and there is a pleural effusion then there must be loss of volume in the lung. There is air present in the right lung and there must be considerable consolidation in the right lung. The expression air bronchogram can be confusing. It refers to air in major bronchi and fluid in the smaller airways such as alveoli and terminal bronchioles. The bronchi stand out as they are filled with air and consolidation in the lung opacifies the radiograph. I suspect there is extensive consolidation here but the pleural effusion makes it difficult to see these abnormalities. I am not sure if this case was externally reviewed but it is important to correct the significant errors here. Competing interests: None declared
Response: Errors in this case 1 August 2009
Atul Gupta, Specialist Registrar in Respiratory Paediatrics Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, Anand Devaraj, Donald S Urquhart, Ian M Balfour-Lynn Send response to journal: Re: Response: Errors in this case	We thank Dr Mcknight for his interest in our picture quiz. In this case, it is the lack of mediastinal shift towards the site of the abnormality (or indeed other radiographic signs of lobar volume loss) that is the important finding. The lack of such displacement would indicate that the opacification in the right lung is not caused by multilobar collapse. We agree that any ambiguity could have been avoided by using the phrase “preservation of volume of the right hemi-thorax”. The predominant abnormality on this radiograph is the lateral density, tracking up the right lung, in keeping with a pleural effusion. In apparent continuity with this, the density extends medially and is likely in large part to be due to pleural fluid as well. Traditional teaching is that in the presence of complete opacification of a hemi-thorax due to a massive pleural effusion without mediastinal shift, then the likely causes (in adults) are: 1) a central bronchial occlusion causing concomitant lung collapse or 2) a mesothelioma that has the effect of “freezing” the hemithorax. However, this radiograph does not demonstrate complete opacification of the right hemi- thorax, and the absence of mediastinal shift away from the effusion, does not exclude the presence of a large right loculated effusion, without collapse [1]. Indeed, how much loculated pleural fluid (adjusting for adjacent compressive atelectasis that is often seen in an empyema) is required to cause mediastinal shift visible on a chest radiograph in a 2 year old is unknown. Compressive atelectasis is often seen adjacent to an empyema, and this may be present in this case. However, the extent of such atelectasis cannot be judged based on the radiograph. We would like to reiterate that there are no air bronchograms (ie air filled bronchi within high attenuation lung [2]) on this radiograph. While the absence of air bronchograms does of course not exclude consolidation, it is another observation that suggests that the extensive opacification in the right lung is not predominantly due to consolidation. Ultimately, ultrasound is the next imaging test of choice. Amongst other uses, it has the ability to more accurately quantify the extent of pleural fluid, versus collapsed or consolidated lung [3]. In this case, ultrasound showed the presence of a large right loculated effusion, which was further confirmed by the drainage of 1 litre of pus from the right hemithorax. References 1. Swishchuk LE. Imaging of the newborn, infant, and young child. 6th ed. 2006. Lippincott Williams & Wilkins. p. 112. 2. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology 2008; 246:697-722 3. Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005; 60 Suppl 1:i1-21 Competing interests: None declared