The elusive Hampton’s hump

Abstract

A 66-year-old man presented to the Emergency Department with a 1-day history of weakness and left-sided chest pain. He had a complex medical history including insulin-dependent diabetes mellitus, coronary artery disease with a history of myocardial infarction, hypertension, chronic renal insufficiency, and history of deep venous thrombosis (DVT). He described the pain as sharp and stabbing in the left side of the chest that was made worse with movement and inspiration. The pain came on suddenly the day before and had remained constant since. The patient had taken nitroglycerin and proproxephene with little relief of his symptoms. The pain was confined to the chest and had no radiation to the arms or jaw. The patient also complained of generalized weakness, nonfocal in nature, that had prevented him from performing the activities of daily living. The patient denied any trauma, fevers, cough, chills, hemopytsis, shortness of breath, or leg swelling. Physical examination revealed an elderly man in no respiratory distress. Cardiovascular examination showed a regular rate and rhythm without murmurs, rubs or gallops. Pulses were equal bilaterally. Pulmonary examination demonstrated mild bilateral crackles. The chest wall was nontender to palpation. The lower extremities had no edema, pain, cords or swelling. The initial work-up of this patient was directed towards a cardiac pathway, considering the patient’s past medical history. Initial management with nitroglycerin, aspirin, and morphine made no improvement in the patient’s symptoms. The patient’s original electrocardiogram (EKG) was unremarkable, as were the laboratory studies. However, the patient’s portable AP chest X-ray study revealed a left-lung-based wedge-shaped opacity not previously seen on prior radiographs (Figure 1). There was also a new small left-sided pleural effusion present. The radiologist thought this opacity was consistent with an infectious process, or a “Hampton’s hump.” Although a pneumonia could explain the chest pain and weakness, the acute onset, history of a DVT, and the finding of a “Hampton’s Hump” prompted a work-up for a pulmonary embolus. With the patient’s history of chronic renal insufficiency, a ventilation-perfusion scan was ordered to establish the diagnosis. A perfusion defect in the same area was deemed a high probability for an acute pulmonary embolism. The diagnosis of pulmonary embolism remains a diagnostic challenge. Standard chest radiographs are often obtained in the initial work-up of pulmonary embolism but are often unrevealing (1). Before newer techniques were discovered, the chest radiograph was the only imaging technique available for aiding in the diagnosis of pulmonary embolism. Multiple radiographic abnormalities have been described by the early radiologists in the diagnosis of pulmonary embolism. In 1940, Hampton and Castleman first described a pleural-based area of increased opacity associated with pulmonary embolism,