Normal Chest Roentgenograms Research Articles

Clinical Course of 91 Consecutive Near-Drowning Victims

Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eight-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows; PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.

Clinical course of 91 consecutive near-drowning victims

Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eighty-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows: PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.

Whole lung tomography in metastatic disease

Because pulmonary metastases in patients with primary neoplasms have both therapeutic prognostic implications, a review was undertaken of 100 patients with primary neoplasms in whom whole lung tomography and chest roentgenography had been performed. Eight (20%) of 28 patients with solitary metastases on conventional films had more than one lesion on tomography. Due to the tomographic findings, therapy was altered in six of those eight. Two (3%) of 72 patients with normal chest roentgenograms had metastases visible on their tomograms. The data indicate the high value of whole lung tomography in determining therapy whenever a solitary metastasis is visible on conventional chest roentgenograms. The 3% pickup rate of metastases in patients with normal chest roentgenograms is less clear-cut but does suggest the contribution tomography can make in patients with potentially curable lesions.

The Clinical Assessment of Selected Patients with Bronchogenic Carcinoma

This paper describes the clinical management of patients with malignant cells in their sputum and a normal chest roentgenogram and those with asymptomatic peripheral pulmonary masses. The source of malignant cells in the sputum of patients with no roentgenographic abnormalities can be localized by tantalum bronchography and fiberoptic bronchoscopy. Peripheral pulmonary masses can be diagnosed preoperatively by needle biopsy or trans-bronchial fiberoptic bronchoscopy with little morbidity and no mortality. These procedures are not necessary, however, if there is firm clinical and roentgenographic evidence of malignancy. Bronchogenic carcinomas presenting as asymptomatic circumscribed peripheral pulmonary masses have a 25% incidence of occult mediastinal lymph node metastases. In view of this relatively high incidence of metastasis, we think mediastinoscopy should routinely be performed prior to thoracotomy in asymptomatic patients with a peripheral pulmonary mass and no roentgenographic evidence of mediastinal widening.

Letter: Pneumatoceles following hydrocarbon ingestion.

Sir.—The article by Bergeson et al, which appeared in the January issue of theJournal(129:49, 1975), was a fine discussion of the stated problem. The management of their first case was, however, suboptimal in my opinion. This 20-month-old boy ingested lighter fluid. He choked, coughed, vomited after ingestion, and was seen in the emergency room that night. He was sent home after a normal chest roentgenogram had been obtained. He was seen in the outpatient clinic the next day with fever, harsh breath sounds, and right middle lobe and left lower lobe infiltrates. At this point he should have been admitted to the hospital. Instead, he was given ampicillin sodium and sent home. The authors themselves point out that pleural effusion, pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumopericardium have been encountered as complications of hydrocarbon ingestion (p 51). Others have reported serious cardiac complications following hydrocarbon ingestion.1Most

Clinical importance of lymphoblasts with T markers in childhood acute leukemia.

Of 48 children with acute lymphocytic leukemia 11 had blast cells with receptors for sheep erythrocytes in their initial bone-marrow aspirates and 37 did not. A comparison of selected clinical features indicated striking differences between the two groups. Leukemia with the receptors was associated with a high proportion of older children, predominantly boys, a thymic mass, and a high white-cell count at diagnosis. In contrast, the 37 children with leukemia without the receptors were generally less than five years of age, with a nearly equal distribution of boys and girls; all but one had normal chest roentgenograms, and only one had a white-cell count greater than 100,000. Thus, the presence or absence of lymphoblasts with sheep erythrocyte receptors--a T-cell marker--distinguishes two forms of childhood acute lymphocytic leukemia, each with a distinct distribution of age and sex as well as other characteristic clinical features.

Persistent Cough and Widespread Pulmonary Involvement in a Young Woman

<h3>History</h3> A 24-year-old black woman was admitted to the hospital with a complaint of persistent cough of three months' duration. She had had normal chest roentgenograms approximately 12 and 6 months before admission for similar complaints. Physical examination demonstrated a comfortable, obese woman with no shortness of breath. Examination of the neck, thorax, and abdomen gave normal findings. No evidence of lymphadenopathy was apparent. Routine complete blood cell count and urinalysis showed no abnormalities. Results of intravenous urography, mammography, and thyroid scan were also normal. Persistent cough remained the sole complaint of the patient. Figures 1 and 2 were obtained on admission. <h3>Diagnosis</h3> Sarcoidosis. <h3>Comment</h3> The posteroanterior and lateral chest roentgenograms disclose a number of large, ill-defined nodular densities varying in diameter from 3 to 5 cm, located mainly in the central and lower zones of both lung fields. The borders of the nodular densities are hazy and fluffy and

Roentgenographically atypical Pneumocystis carinii pneumonia.

Two patients with renal transplants were admitted for evaluation of fever. During the course of hospitalization both had hectic fever and arthralgia. Pulmonary symptoms were absent or minimal. In one patient the admitting chest roentgenogram was entirely normal and in the other only a small focal abnormality was apparent. Hypoxemia occurred even in the presence of normal or nearly normal chest roentgenograms. The diagnosis of Pneumocystis carinii infection was made by bronchoscopic brush biopsy in both patients. Therapy with pentamidine isethionate was successful. It is suggested that in patients with renal transplants and in others with similar immonosuppression, even with a normal chest roentgenogram, Pneumocystis carinii infection be considered as the cause of a fever of unknown origin. This should be evaluated initially with blood gas studies; if these are abnormal, further studies, including biopsy, are justified.

Mediastinal Mass in a Sick Infant

History Cough and slight fever developed in a 3-month-old infant. The physical examination gave normal results. A chest roentgenogram was obtained. Diagnosis Normal chest roentgenogram with normal thymic shadow. Discussion: The chest roentgenogram shows normal bony structures, lung fields, and pleura. The heart is not enlarged, but there is a shadow projecting superiorly and laterally to the right of the heart and mediastinum (Fig 1, top). This shadow has a subtle, wavy lateral margin with indentations exactly opposite the anterior ends of the ribs (Fig 1, bottom). This is the thymic wave sign, first described by Mulvey,1which indicates that the shadow in question is the thymus. Intimate contact between the lateral border of normal soft thymic tissue and the anterior ends of the ribs (or their chondral extensions) creates this characteristic roentgenographic appearance. Thymic tumors or other masses in the anterior mediastinum are generally firmer and not positioned

Maximal extent of visualization of bronchial tree by flexible fiberoptic bronchoscopy.

Eight patients with hemoptysis but with normal chest roentgenograms were examined with a 5.2-mm flexible fiberoptic bronchoscope to determine the extent of the tracheobronchial tree available for inspection. All third order, 74 per cent of fourth order, and 38 per cent of fifth order bronchi were entered. Beyond these limits of bronchoscopic entrance, all fourth order, 86 per cent of fifth order, and 56 per cent of sixth order bronchi were visualized. This instrument makes available a far greater amount of the bronchial tree for inspection and for collection of specimens than has previously been available.

Cytology in Fiberoptic Bronchoscopy: Comparison of Bronchial Brushing, Washing and Post-Bronchoscopy Sputum

Fiberoptic bronchoscopy was used to study 103 patients with suspected pulmonary neoplasm. Material for cytologic examination was obtained from bronchial brushing, bronchial washing and post-bronchoscopy sputum. In 87 patients, a definite diagnosis was made. The bronchial brush material was positive in 41 of the 46 patients with carcinoma. Bronchial washing plus post-bronchoscopy sputum examination identified only one additional neoplasm. Of the 17 patients with hemoptysis and a normal chest roentgenogram a diagnosis was achieved in 14, but no carcinomas were found. It may be preferable to repeat the bronchial brushing rather than rely on bronchial washing or post-bronchoscopy sputum when the initial brushing is not diagnostic. Fiberoptic bronchoscopy was used to study 103 patients with suspected pulmonary neoplasm. Material for cytologic examination was obtained from bronchial brushing, bronchial washing and post-bronchoscopy sputum. In 87 patients, a definite diagnosis was made. The bronchial brush material was positive in 41 of the 46 patients with carcinoma. Bronchial washing plus post-bronchoscopy sputum examination identified only one additional neoplasm. Of the 17 patients with hemoptysis and a normal chest roentgenogram a diagnosis was achieved in 14, but no carcinomas were found. It may be preferable to repeat the bronchial brushing rather than rely on bronchial washing or post-bronchoscopy sputum when the initial brushing is not diagnostic.

Prévalence de la bronchite chronique dans différents groupes socio-professionnels

In order to estimate the incidence of chronic bronchitis in the steel industry, a group of 200 workers between 40 and 60 years of age, with normal chest roentgenograms were examined. In addition to es

Hepatic granulomatosis and sarcoidosis.

The etiology of hepatic granulomatosis discovered in patients with normal chest roentgenograms is controversial. Among 18 such patients studied in recent years, sarcoidosis was identified as the cause in 15 by demonstration of granulomatous inflammation in extrahepatic tissues, employing a variety of biopsy methods. Serum angiotensin levels were raised in all 10 patients tested and gallium scans were helpful in four of six cases. Prolonged fever was the most common symptom, but three patients had severe right upper quadrant pain, a manifestation of hepatic sarcoidosis not previously described. Improvement on corticosteroids was observed in the 14 treated patients, but incomplete response led to use of cytotoxic drugs in three cases. Sarcoidosis presents with normal chest roentgenograms more often than is appreciated and appears to be a common cause of unexplained persistent hepatic granulomatosis. A firm diagnosis should be established since treatment is long and frustrating. The prognosis is good but treatment for years is required in most cases.

Pulmonary Dysfunction in Rheumatoid Disease

During an investigation of pulmonary dysfunction in 41 consecutive patients with classical or definite rheumatoid arthritis, it was found that 41.4 percent had abnormalities of pulmonary diffusion. Generally the physiologic profile was one of decreased vital capacity, decreased total lung capacity, and arterial hypoxemia; these abnormalities were supported by the pathologic findings of percutaneous lung biopsy. All patients showed changes of interstitial fibrosis. Usually, the patients were not symptomatic, and 47.0 percent had normal chest roentgenograms. The type of treatment received, level of rheumatoid factor, duration of disease, and American Rheumatism Association (ARA) stage of disease failed to correlate with the presence or absence of pulmonary dysfuntion. The clinical significance of pulmonary fibrosis in rheumatoid patients is unknown, and the disease seems to be mild clinically and only slowly progressive. It is concluded that pulmonary fibrosis is common in rheumatoid disease and should be regarded as an expected manifestation, rather than an unusual complication, of the systemic process connoted by the term rheumatoid disease.

The chest roentgenogram in the early diagnosis of tuberculous meningitis in children.

The chest roentgenograms of 180 children with tuberculous meningitis were reviewed. All x-ray films of the chest were made early in the course of the disease or before the diagnosis had been established. Forty-three percent of the children had normal chest roentgenograms, 23% had signs of disseminated miliary tuberculosis and 10% had calcifying primary intrathoracic tuberculosis. Normal chest roentgenograms should not be used to exclude tuberculous meningitis in the differential diagnosis.

Relation of kveim-antigen reaction to lymphadenopathy. Study of sarcoidosis and other diseases.

Kveim tests in 37 selected patients with sarcoidosis demonstrated that a reaction could be related to persistent lymphadenopathy and not to duration or activity of illness. Fourteen asymptomatic patients with marked enlargement of the mediastinal and hilar lymph nodes of long duration all reacted strongly. Positive tests occurred in only three of 12 patients having disease of recent onset with minimal adenopathy, and in only one of 11 with active hepatic or cutaneous sarcoidosis and normal chest roentgenograms. The demonstration that the reaction is more closely related to lymphadenopathy than to granulomatosis led to tests in patients with lymph-node enlargement due to other diseases. Typical reactions were obtained in patients with chronic lymphatic leukemia, tuberculous adenitis, infectious mononucleosis and nonspecific cervical adenitis. The Kveim test appears to be an immunologic reaction associated with persistent lymphadenopathy of diverse causes.

Rapid Growth of a Pleural Mesothelioma

A patient with diffuse pleural mesothelioma presenting as a large mass in the left hemithorax is described. Despite a normal chest roentgenogram three months earlier and symptoms of only three days’ duration, the patient expired within three weeks of admission. This confirms the potential rapid growth of this malignancy.

Evaluation of the Lung Scintiphoto as a Screening Test for Pulmonary Disease

SummaryA method is described for the manufacture of 99mTechnetium lung scanning agent that incorporates nearly 100% of the technetium eluate and can be made from bulk solutions in about sixteen minutes. These particles were used to study the value of the lung scintiphoto as a screening procedure for pulmonary disease; comparing it with the posterior-anterior and left lateral chest roentgenogram, and the timed vital capacity. Many perfusion defects, sometimes multiple, were found to be present in lungs with normal chest roentgenograms. Perfusion abnormalities were noted in people with normal and near normal timed vital capacities. We feel that the lung scintiphoto may be a useful adjunctive screening test for pulmonary disease.

Restoration of Pulmonary Blood Flow

To the Editor. —In their Original Article Restoration of Pulmonary Blood Flow After Pulmonary Embolism, in the February issue (Arch Intern Med 125 :241-247,1970) Winebright and associates have corroborated their clinical impressions of acute pulmonary embolism with lung scans rather than pulmonary arteriography. Unfortunately, pulmonary photoscanning with iodinated I 131 serum albumin, aggregated is quite nonspecific; in one study, 40% of the patients with obstructive lung disease and abnormal scans had normal chest roentgenograms. 1 The authors' statement ... that elderly patients without clinical evidence of chronic lung disease usually have normal perfusion patterns on lung scanning. is open to serious question. We recently studied serial lung scans in a group of elderly patients with no clinical evidence of pulmonary embolism and found widespread, persistent perfusion abnormalities in 57 of 80, 30 of whom had normal chest roentgenograms and laminagrams. 2 Although the reason for these defects is not clear, it

Diagnostic Accuracy of Exfoliative Pulmonary Cytology

he increased incidence of bronchogenic carcinoma has brought with it diagnostic problems, especially in the evaluation of abT normal chest roentgenograms. In primary carcinoma of the lung, bronchial biopsy will reveal the diagnosis in about one-third of cases. Biopsy of scalene lymph nodes in the absence of palpable nodes will demonstrate the presence of metastatic carcinoma in about 10 to 20% of cases. An outcome of the development of exfoliative cytology during the last two decades has been the growing dependence of thoracic surgeons on cytological examination of respiratory secretions to diagnose lung cancer. It is not generally realized, however, that not only can cytological examination of sputum or bronchial aspirate be used to diagnose the presence of bronchogenic carcinoma; it also can be applied to the histological typing of the neoplasms. In our medical center the presence of malignant cells in sputum or bronchial aspirate is regarded as reliable evidence that a malignant neoplasm exists in the respiratory tract. A question has been raised, however, concerning the reliability of cytological examination in the typing of bronchogenic carcinomas. T o answer this question, we have reviewed our experience with 104 cases of bronchogenic carcinoma. In these cases a definite statement as to the type of carcinoma was arrived at by cytological examination, and there was histopathological material to confirm or refute the cytological typing.