Blunting Of Costophrenic Angle Research Articles

Thoracic Complications in Supracostal Percutaneous Nephrolithotomy.

Due to the risk of pleural injury leading to thoracic complications, many urologist still hesitate to perform supracostal puncture during percutaneous nephrolithotomy. Our aim of this study was to evaluate the thoracic complications in supracostal access percutaneous nephrolithotomy. This is a retrospective analysis of 101 patients who were treated with supracostal access percutaneous nephrolithotomy at our institute from September 2013 and December 2019. Indications for supracostal punctures were staghorn 28(27.7%), middle calyceal stones 10(9.9%), pelvic stones 29(28.7%), complex inferior calyceal stones 26(25.7%), upper calyceal stone 10(9.9%)and upper ureteric stone17(16.8%).The intercostal space between the 11th and 12th ribs was used in all the cases. Among the 101 patients who undergone percutaneous nephrolithotomy by supracostal access, three patients (2.97%) had pleural injury. Among them one patient developed hydrothorax and needed chest tube insertion and remaining two patients had minimal pneumo thorax with blunting of costo-phrenic angle, which was managed conservatively. The lung parenchymal or other viscera injury was not observed in our study. Most punctures were, a single supracostal superior calyceal access 18(17.8%) and middle posterior calyceal access 88(82.2%), except for staghorn and multiple complex lower calyceal calculi needed multiple tracts 23(22.8%). Complete clearance was observed in 77(76.2%) patients. The supracostal puncture was a safe and effective approach with high stone clearance rate and acceptable morbidity in selected cases of staghorn, upper ureteral, and upper calyceal calculi. It should be adapted whenever needed and should not be avoided due to fear of chest complications.

Delayed massive hemothorax from pulmonary laceration complicating rib fractures: a rare case presentation

Background: The incidence of delayed hemothorax from blunt chest trauma was only up to 7.4%, massive hemothorax being much rarer. Case Presentation: We report a case of this uncommon situation involving a 65-year old gentleman with alleged motor-vehicle accident (MVA) sustaining multiple right 2nd to 8th rib fractures. Despite initial in-patient monitoring, he presented to us again on Day-7 post-MVA with acute shortness of breath and chest pain. Chest radiograph showed homogenous opacity over right lung field with the blunting of costophrenic angle. Right thoracostomy tube drained 800 ml of frank blood upon insertion with a total of 1,250 ml within 12 hours. The patient was subsequently transferred to cardiothoracic center for definitive care. Conclusion: Therefore, the possibility of delayed sequelae following blunt chest trauma should be considered and communicated to the patient to encourage vigilance and home monitoring. Despite rarely requiring emergency surgery, delayed massive hemothorax is potentially life threatening.

A rare presentation of tuberous sclerosis complex: Complicated renal cyst leads to sepsis

Introduction: Tuberous sclerosis complex is a rare autosomal dominant genetic disease, having multi systemic involvement. Κidneys are affected up to 80% of patients, in the form of renal angiomyolipomas, renal cysts or renal cell carcinoma. Renal cysts are presented as single or multiple lesions that are infrequently symptomatic. Rarely, tuberous sclerosis coexists with polycystic kidney disease with poor prognosis through renal failure or hematuria. The complication of the renal cysts with the form of abscess is extremely rare. Here we present a case of tuberous sclerosis in which complicated renal cyst led to sepsis. Case Report: A 30-year-old female, with a history of tuberous sclerosis, presented with a week-long fever and a left pleuritic chest pain. Chest radiograph disclosed a left costophrenic angle blunting. Thoracic ultrasound followed, surprisingly revealed a big subdiaphragmatic renal cystic formation pressing against left hemidiaphragm, not previously known. While the patient was septic with no reply to the empirical antibiotic therapy and with a gradually worsening dyspnea, the cystic drainage was decided, resulted in a fast clinical improvement. Proteus mirabilis was cultured from cystic content. Conclusion: Renal disease is the most common cause of death in population affected by tuberous sclerosis. Thus, monitoring and serial radiologic examination are necessary to improve the prognosis of kidney damage. Abscess following simple renal cyst infection constitute another rare but potentially life-threatening renal complication should be taken under consideration. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 2, February 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(2):106–110. www.ijcasereportsandimages.com Kotsiou et al. 106 CASE REPORT OPEN ACCESS A rare presentation of tuberous sclerosis complex: Complicated renal cyst leads to sepsis Ourania S. Kotsiou, Konstantinos I. Gourgoulianis

Avoiding iatrogenic harm by integrating physical examination findings with a point-of-care lung ultrasonography.

Sir, A 50-year-old male presented to the hospital with the chief complaint of shortness of breath associated with high-grade fever and productive cough with a yellowish expectoration. He was confused, tachypnoeic and tachycardic, but without hypotension. Examination of the chest revealed right-sided basal coarse crepitations, but with equal air entry and normal percussion note. Trachea was central in location. Portable chest X-ray was suggestive of right-sided large pleural effusion, with blunting of costophrenic angle [Figure 1]. Laboratory investigations revealed elevated white blood count with neutrophil predominance and elevated blood urea level. Patient was admitted to Intensive Care Unit with the diagnosis of severe community acquired pneumonia with pleural effusion. Patient was started on injection Ceftriaxone and Azithromycin. Therapeutic thoracocentesis was planned. Chest X-ray findings did not correlate with the physical examination findings of chest. Bedside point-of-care the lung ultrasonography was performed by the intensivist. Multiple B-lines with increased lung water content was noted in right lower zone, but without pleural effusion [Figure 2]. Chest X-ray was repeated, which showed consolidation of right lower zone, but the costophrenic angle was visible. Thoracocentesis was deferred. With the suspicion of radiological artefact, the first chest X-ray was discussed with the radiologist. The artefact was due to intensifying light exposure while positioning the X-ray film. Figure 1 Chest X-ray suggestive of right-sided large pleural effusion with blunting of right costophrenic angle Figure 2 Lung ultrasound of right lower zone showing multiple B-lines with increased lung water content Diagnostic errors are not uncommon and are potentially preventable. Procedural complications are an important cause of adverse events.[1] It contributes to increased length of hospital stay, increased cost and higher morbidity. Minimizing iatrogenic harm is an important component of decreasing morbidity associated with critical care. It complies with one of the fundamental principles of ethics in critical care - nonmaleficence.[2] The traditional chest physical examination alone is not sufficiently accurate to diagnose pneumonia.[3] Point-of-care lung ultrasonography is helpful and accurate in diagnosing the cause of acute respiratory failure.[4] The learning curve for acquiring skills to diagnose lung consolidation using a lung ultrasonography is steep. It can be attained in <6 weeks when performed on a daily basis. The intra and inter-observer variability is small and is <5%.[5] Iatrogenic pneumothorax is a common complication of the thoracocentesis, with overall rates of 6.0%. Pneumothorax is more likely following therapeutic thoracocentesis.[6] In our patient, by integrating the physical examination findings with a bedside point-of-care lung ultrasonography, we were able to avoid unnecessary thoracocentesis, averting the preventable and possible iatrogenic harm to the patient.

Unusual Presentation of Foreign Body Aspiration as Pleural Effusion in an Infant

To the Editor : Foreign body aspiration presenting as isolated pleural effusion without an underlying pneumonia is rare. So far only one case has been reported [1]. An 11-mo-old boy presented with a history of sudden onset of fast breathing and retractions since last 4 h. He was hemodynamically stable with 95 % saturation under hood oxygen. Auscultation revealed decreased air entry on the left side. Chest radiography showed pleural effusion with collapse lung on left side with ipsilateral mediastinal shift. Ultrasound chest showed left sided pleural fluid of 6 mm depth. Diagnostic pleural tap showed a transudative fluid with no pus cells or bacteria. Total blood WBC count was 18,600 with 78 % polymorphs. The child had a fever spike of 101 °F 2 h after admission. Hence, a possibility of community acquired pneumonia with synpneumonic effusion was kept and child was started on intravenous ceftriaxone. After 48 h of treatment, the child’s respiratory distress did not improve and air entry was persistently decreased on the left. Blood culture and pleural aspirate culture were sterile, no further fever spikes. Repeat chest radiography showed a partially expanded lung with only minimal blunting of costophrenic angle on the left and hyperinflated lung on the right. Hence, on clinical grounds, a diagnostic fibreoptic bronchoscopy was done which revealed a Bengal gram piece in the left intermediate bronchus. Urgent rigid bronchoscopy was done and two pieces of Bengal gram were removed from the left intermediate bronchus. Post procedure the child was treated with intravenous steroids and adrenaline nebulisation. The child showed dramatic improvement, respiratory distress settled. Repeat chest radiography 12 h later was normal. Blood counts normalised to a total count of 10,600 with 63 % polymorphs and the child was discharged after 48 h. There is a case report of a 60-y-old man presenting with pleural effusion due to a candy wrapper aspiration [2]. But the effusion was secondary to pneumonia. Foreign body aspiration presenting as isolated pleural effusion is rare. So far only one case has been reported, a 3-y-old child with a vegetable foreign body presented with pleural effusion without pneumonia [1]. 750 mL of transudative pleural fluid was drained and the vegetable matter was removed by bronchoscopy. The exact mechanism is not known. The possible mechanisms are either it may be a result of an inflammatory response to a foreign body in the bronchus or it is secondary to the atelectasis and the sudden more—negative intrathoracic pressure. To conclude, in our case, poor response to conventional treatment, persistently decreased air entry and differential inflation even after the resolution of pleural effusion prompted us to investigate for a possible foreign body aspiration. This possibility should always be considered in any child presenting with respiratory symptoms not responding to conventional management.

Glomus tumor of the trachea

A 76-year-old man presented with a 1-week history of fever. His medical history included prostate cancer, coronary artery disease and diabetes mellitus. Physical examination was unremarkable except left basal crackles on auscultation. Chest radiograph showed left costophrenic angle blunting with ground-glass opacity. Thoracentesis was performed and pleural effusion profile showed lymphocyte predominant exudates. For evaluation …

P10 Asbestos-induced diffuse pleural thickening—a continuing problem

IntroductionAsbestos-induced diffuse pleural thickening (DPT) remains a relatively common but poorly understood disease.MethodsWe reviewed the clinical, physiological and radiological features of patients referred to our department for assessment. Diagnosis was...

Clinical Analysis of Video Assisted Thoracic Surgery for the Treatment of Thoracic Empyema

Sang-Gi Oh, M.D.*, Sang-Yun Song, M.D.**, Chi-Hyeong Yun, M.D.*, Kook-Ju Na, M.D.*, Kang-Eun Kong, B.A.**, Song-Ran Park, B.A.**, Sang-Hyung Kim, M.D.*. Korean J Thorac Cardiovasc Surg 2010;43:139-43. https://doi.org/10.5090/kjtcs.2010.43.2.139

Continuous Murmur After Ascending Aortic Surgery

We report a case of an aortic root pseudo aneurysm (PSA) that ruptured into the right pulmonary artery (RPA) causing a large left-to-right shunt and congestive heart failure. A 56-year-old man presented with New York Heart Association class III congestive heart failure 6 years after insertion of a Freestyle aortic valve bioprosthesis with reimplantation of the coronaries as button anastomoses to treat a localized aortic root dissection. Physical examination demonstrated a grade 4/6 continuous murmur at the left sternal border, bibasilar crackles, left lung base dullness, ascites, and pedal edema. Chest x-ray (portable anteroposterior film, Figure 1) showed marked cardiomegaly, prominent pulmonary vasculature, and a left pleural effusion suggestive of left ventricular volume overload. Twelve-lead ECG (Figure 2) showed sinus rhythm, biatrial enlargement, and biventricular hypertrophy with right ventricular …

Broncholithiasis

A 47 year old female who had past history of incomplete treatment for pulmonary tuberculosis presented with increased breathlessness, generalized swelling and loss of ap-petite for last one month. X-ray chest PA view showed bilateral fibrocalcific opacities with blunting of costophrenic angle on both sides. She underwent bronchoscopy to collect bronchial wash to rule out relapse of tuberculosis. On bronchoscopy a loose broncholith with sharp and speculated margins were detected in right middle lobe bronchus. This broncholith was successfully removed through flexible bronchoscope without any complications.

Pleural effusions: patterns on ventilation-perfusion lung scans.

Perfusion and ventilation abnormalities created by pleural effusions can interfere with the interpretation of the lung scan. This retrospective study identified and evaluated the specificity of scintigraphic patterns for pleural effusion. Ninety-two ventilation-perfusion lung scans were analyzed for the following signs of pleural effusion: presence of fissures, straightened or concave lung borders, costophrenic angle blunting, and attenuation of lung activity by interposed fluid. The findings later were correlated with chest radiographs. Of 25 pleural effusions detected by chest radiography, scintigraphy predicted 14 (specificity, 86%). In all of these cases, there was agreement with the chest radiograph (specificity, 100%). The fissure sign and the straight-concave border sign were equally reliable for the prediction of pleural fluid. Costophrenic angle blunting was never seen as the sole indicator of pleural fluid, and attenuation was seen alone in only one case. Another finding observed during this evaluation was absent ventilation at the lung base with preserved perfusion. Scintigraphic patterns may not be reliable in obstructive lung disorders and diseases with altered lung compliance. The recognition of scintigraphic patterns of pleural effusions on ventilation-perfusion scans can improve the clinical value of lung scintigraphy by reducing the number of indeterminate readings.

Computerized delineation and analysis of costophrenic angles in digital chest radiographs

The authors developed a computerized method for delineating the costophrenic angles in digital posteroanterior chest radiographs to derive quantitative information that allows for detection of abnormal blunting of the costophrenic angle. An automated lung-segmentation scheme was used, and small regions of interest were placed in the approximate position of the costophrenic angles in 600 clinical posteroanterior chest radiographs to define a subimage for further analysis. The diaphragmatic aspect of the costophrenic angle was delineated based on column-wise contrast information, and the costal aspect was delineated based on row-wise gray-level maxima. The angle formed by the convergence of these two aspects provided the basis for assessing abnormality. Curve fitting was then performed on these segments to form a continuous costophrenic angle delineation. The computer-determined angles for 1,166 hemithoraces were compared with independent diagnostic assessments by a radiologist. An encouraging level of agreement was found between these two measurements, with the area under the receiver operating characteristic curve attaining a value of 0.83. This delineation method enhances the automated lung-segmentation scheme. Quantitative information obtained from the costophrenic angles can be used for automatic evaluation of the presence of costophrenic angle blunting, which may indicate the presence of pleural effusion.

Automated lung segmentation in digital posteroanterior and lateral chest radiographs: Applications in diagnostic radiology and nuclear medicine

Automated segmentation of anatomic regions in digital radiographs is a key element of computer‐aided diagnostic (CAD) methods. Computerized methods for automatically segmenting the aerated lung fields from digital posteroanterior (PA) and lateral chest radiographs have been developed. The methods are based on gray‐level thresholding techniques, including iterative global gray‐level thresholding and local gray‐level thresholding, thus reducing the need for a priori assumptions regarding overall lung morphology. Consequently, this method is particularly applicable to the detection of abnormal asymmetry in PA radiographs, where pathological processes may produce gross alterations in the appearance of radiographic lung anatomy. An anatomic region of particular interest is the costophrenic angle. The method described lends itself to the automated assessment of costophrenic angle blunting, for which a technique has been developed. Another application of this method crosses into the field of nuclear medicine. Radionuclide lung scans are typically used in conjunction with chest radiographs for diagnostic purposes. An automated method for registering digital PA and lateral chest radiographs with the perfusion and ventilation images of a lung scan has been developed. These computerized techniques may be incorporated into future CAD schemes and may potentially aid radiologists in the interpretation and assessment of medical images.

Chest radiography: comparison of high-resolution digital displays with conventional and digital film.

This study was performed to compare the performances of observers using three display formats for chest radiography. The display formats were conventional radiographs, digitized radiographs (2,048 X 2,048 X 12 bits) printed on laser film, and digitized radiographs (2,048 X 2,048 X 12 bits) displayed on a high-resolution (2,560 X 2,048 X 12-bit) gray-scale display. The test set for the study consisted of 163 cases. Sixty-four of the cases were normal, whereas the 99 remaining cases demonstrated one or more common radiographic abnormalities. Nine abnormalities were selected for analysis: costophrenic angle blunting, interstitial disease, atelectasis, pneumothorax, parenchymal mass, consolidation, obstructive disease, hilar/mediastinal mass, and apical scarring. Six experienced general radiologists participated in the evaluation. Receiver operating characteristic curves were generated for each abnormality and display format. The results indicate that, while the three display formats are equivalent for the detection of some abnormalities, detectable differences in observer performance may be seen even at 2,048 X 2,048 X 12 bits for the detection of obstructive disease, pneumothorax, interstitial disease, and parenchymal masses.

Massive organized intrapericardial hematoma mimicking constrictive pericarditis

Blunt and penetrating chest trauma as a cause of hemopericardium with subsequent cardiac tamponade and/or constrictive pericarditis due either to the presence of intrapericardial clotted blood or chronic inflammation has been well described.1-3 We describe here an unusual patient who presented with massive organized intrapericardial hematoma with the hemodynamic characteristics of chronic constrictive pericarditis 4 years after suffering blunt chest trauma. The diagnostic studies, including two-dimensional echocardography and cardiac CT scan which aided in establishing the preoperative diagnosis of the etiology of the constriction, are demonstrated. A 25-year-old man with a ?-month history of ankle swelling and a 2-month history of abdominal swelling was admitted for evaluation. Four years prior to admission, the patient was involved in a motor vehicle accident in which he suffered chest trauma from the steering wheel. No chest x-ray examination was obtained at that time. He described hemoptysis associated with that incident. During the 3Y2 year interim he denied any subsequent chest trauma. His major symptom at the time of admission was dyspnea on exertion. On physical examination he appeared chronically ill. There was marked jugular venous distention with prominent x and y descent. An early diastolic sound was present on cardiac examination, and the point of maximal intensity was only faintly palpable in the sixth intercostal space at the anterior axillary line. There was marked tense ascites, the liver was palpable 13 cm below the right costal margin and was not pulsatile, and trace pretibial edema was present. An ECG demonstrated sinus tachycardia and low voltage. Chest x-ray examination revealed bilateral costophrenic angle blunting and cardiomegaly. The left heart border was markedly irregular and “tented” (Fig. 1). Cardiac catheterization revealed elevated end-diastolic pressures with equalization of diastolic pressures between the right atrium, right ventricle, and left ventricle. The intracardiac pressures were (mm Hg): right atrium (mean 15), right ventricle (30/15) with characteristic diastolic dip and plateau, pulmonary artery (30/19), and pulmonary artery wedge (mean 19). No significant (greater than 10 mm Hg) respiratory variation in pressures was noted. Cineangiography by contrast injection into the low right