Endgames Picture quiz

Gradually worsening shortness of breath

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c396 (Published 04 February 2010) Cite this as: BMJ 2010;340:c396
  1. Andrew Baldwin, foundation year 1 doctor1,
  2. David Howlett, consultant radiologist1,
  3. David Maxwell, consultant respiratory physician1
  1. 1Eastbourne District General Hospital, East Sussex Hospitals Trust, Eastbourne BN21 2UD
  1. Correspondence to: A Baldwin a.baldwin{at}doctors.org.uk

    A 38 year old woman who smoked presented to her general practitioner with intermittent shortness of breath and wheeze. She admitted smoking 15 cigarettes a day for the past 20 years. A diagnosis of asthma was made and appropriate inhalers prescribed. Over the next few months she re-presented to her doctor several times with persistent productive cough and increasing shortness of breath. Symptoms were treated as an infective exacerbation with repeated courses of antibiotics. Despite continued treatment with bronchodilators and inhaled steroids little clinical improvement was seen. She returned intermittently to her general practitioner with worsening shortness of breath. Initially this was evident only on exertion, but over the course of two years it began to limit even mild activity. Auscultation showed decreased breath sounds in the lower zones with increased resonance to percussion. Simple spirometry performed at the general practitioner’s surgery showed prolonged expiration and airflow obstruction.

    She was referred to a chest physician, and chest radiography was performed as part of her initial investigations (fig 1).

    Fig 1 Chest radiograph


    • 1 What are the radiological findings?

    • 2 What is the likely diagnosis?

    • 3 What further investigations would you request?

    • 4 How would you manage this condition?


    1 What are the radiological findings?

    Short answer

    The chest radiograph shows hyperinflation with bullous emphysematous changes in the lower zones bilaterally (fig 2).

    Fig 2 Chest radiograph of a patient with α1 antitrypsin deficiency showing marked emphysema in the lower zones

    Long answer

    Chest radiography in patients with α1 antitrypsin deficiency typically shows hyperinflation and reduced lung markings; it can also show bulla formation associated with emphysematous changes.1 Areas are also described as oligaemic—lacking the usual pattern of branching blood vessels.2 The lung bases are often affected in these patients, whereas in patients with typical COPD emphysema is usually apically distributed.3 This …

    View Full Text

    Sign in

    Log in through your institution

    Free trial

    Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
    Sign up for a free trial