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Endgames Picture Quiz

Dyspnoea in a 60 year old man

BMJ 2010; 341 doi: (Published 07 July 2010) Cite this as: BMJ 2010;341:c3404
  1. Yuri K Gupta, specialist registrar in radiology,
  2. Asif A Mazumder, specialist registrar in radiology,
  3. David V Hughes, consultant radiologist,
  4. David C Howlett, consultant radiologist
  1. 1Eastbourne District General Hospital, King’s Drive, Eastbourne, East Sussex BN21 2UD
  1. Correspondence to: Y Gupta yurikg{at}

    A previously well 60 year old man was referred by his general practitioner with a six week progressive history of exertional shortness of breath, without cough, wheeze, or pain. He was a non-smoker. On auscultation his chest was clear. His oxygen saturation was 98% on air, with a respiratory rate of 15 breaths/min. He was afebrile, with a pulse rate of 78 beats/min and blood pressure of 160/95 mm Hg. Physical examination showed enlarged bilateral neck nodes in the anterior cervical chain. Chest radiography was performed (fig 1).

    Fig 1 Chest radiograph


    • 1 What are the radiographic findings?

    • 2 What is the differential diagnosis?

    • 3 What further investigations should be arranged?


    1 What are the radiographic findings

    Short answer

    The radiograph shows symmetrical lobular enlargement of both pulmonary hila, with no signs of cardiomegaly or vascular abnormality (fig 2). This appearance is consistent with bilateral hilar lymphadenopathy.

    Fig 2 Chest radiograph showing bilateral hilar lymphadenopathy (arrows)

    Long answer

    Bilateral hilar lymphadenopathy can be defined as evidence of bilateral enlargement of the hilar nodes, commonly discovered on a chest radiograph.1 It can manifest on chest radiography as abnormal hilar density, size, or shape. Hilar adenopathy appears as round or lobulated abnormal soft tissue arising from the hila. Lack …

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