Endgames Picture Quiz

A breathless woman with asthma

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4008 (Published 07 October 2009) Cite this as: BMJ 2009;339:b4008
  1. Robert H Thomas, specialist registrar in radiology,
  2. Christopher Burke, specialist registrar in radiology,
  3. David Howlett, consultant radiologist
  1. 1Eastbourne District General Hospital, Eastbourne BN21 2UD
  1. Correspondence to: R H Thomas roberththomas{at}gmail.com

    A 36 year old housewife presented to the accident and emergency department because of increasing breathlessness, wheeze, and productive cough over the past two weeks. She had a history of asthma, which was well controlled with inhalers, but had no other history of note and was a non-smoker.

    On examination, she was dyspnoeic but afebrile, with a prolonged expiratory wheeze at the left base.

    Posteroanterior chest radiography was performed as part of her initial investigations (fig 1).

    Fig 1 Posteroanterior chest radiograph

    Questions

    • 1 What radiological abnormality is present?

    • 2 What is the most likely cause considering her history?

    • 3 How would you treat her?

    Answers

    Short answers

    • 1 The chest radiograph shows a triangular shadow of soft tissue density behind the heart in the left lower zone. It also shows a loss of clarity in the adjacent descending thoracic aorta and the left hemidiaphragm in its medial portion, with depression of the left hilum. These features are consistent with left lower lobe collapse.

    • 2 In a patient of this age with known asthma, the most likely cause is mucous plugging and bronchiole obstruction. In older patients or smokers, the most common cause of lobar collapse is a stenosing lesion secondary to bronchogenic carcinoma.

    • 3 The patient should …

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