Normal Chest X-ray Film Research Articles

P3.04-045 Primary Lung Cancer Presenting as Pneumothorax: Topic: Miscellaneous II

Analysis of our patients with primary lung cancer presenting as pneumothorax. Between 2010 -2015 we treated in our clinic among 338 adults (258 men and 80 women) presenting with spontaneous pneumothorax, there were nine men and two woman with lung cancer: Seven squamous cell carcinoma, three adenocarcinoma and one oat cell carcinoma. Pneumothorax led to the diagnosis in 11 cases and the remaining occurred as a complication of known neoplastic disease. The average age was 60 years from (32-72 years old). We analyze these 11 cases treated in our hospital. In patients with normal chest x-ray film findings after lung expansion, further investigation for neoplastic disease is not justified. But we need to perform and chest CT and other investigation in patients with, heavy smoking, chronic bronchitis, bullous emphysema and incomplete lung expansion after chest drainage also patients with age over 50 years old. The occurrence of a pneumothorax in patients with lung cancer, worsening prognosis. Five-year survival is poor, suggesting that lung cancers present as pneumothorax at an advanced stage of disease.

Mechanical Occlusion of the Inferior Vena Cava: An Unusual Complication After Repair of Pectus Excavatum Using the Nuss Procedure

We describe the case of a 13-year-old girl with a pectus excavatum in whom acute occlusion of the inferior vena cava developed after a nuss repair. In this hemodynamically unstable patient, we evaluated the possibility of a penetrating injury to the thoracic and abdominal structures before confirming the diagnosis of inferior vena cava obstruction with a venogram. Removal of the nuss bar relieved the unexpected problem.

Evaluation of workers exposed to dust containing hard metals and aluminum oxide.

Fourteen worker exposed to hard metals and aluminum oxide were evaluated. Six heavily exposed workers underwent bronchoscopy and bronchoalveolar lavage, and five workers underwent transbronchial biopsy. Microchemical analysis of transbronchial biopsies showed a high lung burden of exogenous particles, especially metal related to their hard metals exposure. Lung tissue and cellular changes, which were associated with exposure to hard metal and aluminum oxide, corresponded well with the microanalytic test results. Three workers had at biopsy diffuse interstitial inflammatory changes: two of them were asymptomatic with normal chest X-ray films, and one had clinically evident disease with severe giant cell inflammation. Two other workers showed focal inflammation. The worker showing clinical disease and one asymptomatic worker with interstitial inflammatory changes had evaluated bronchoalveolar lavage fluid-eosinophilia counts. These two were father (with clinical disease) and son (asymptomatic).

Cardiac herniation producing tamponade: the critical role of early diagnosis.

Rupture of the pleuropericardium (PP) occurs rarely, with most patients dying of associated injuries before arriving at the hospital. Among patients who initially survive, the diagnosis is often delayed until cardiogenic shock secondary to cardiac herniation is evident. The records of 10 patients with PP lacerations and cardiac herniations were reviewed. All but one patient had a normal chest x-ray (CXR) film on admission. After the patients became symptomatic, seven of nine had abnormal findings on CXR film demonstrating herniation of the heart into the left hemithorax. The other two patients underwent surgery without a repeat CXR film. Except for one who was taken directly to the operating room, all patients had been previously stabilized before developing cardiogenic shock, on average 9 hours after admission. Operative therapy was closure of the pericardium for five patients and completion pericardiotomy for the others. All survivors developed significant complications, and four of them died. The diagnosis of PP rupture should be considered for patients with multiple trauma who develop sudden and unexpected cardiogenic shock after their initial condition has been stabilized. A repeat CXR film is diagnostic in most cases and should be used as the most efficient and expeditious route to making the diagnosis.

Acute Lupus Pneumonitis With Normal Chest Radiograph

Patients with acute lupus pneumonitis (ALP) usually have hypoxemia, patchy infiltrates evidenced on a chest x-ray film, and an incomplete response to corticosteroids with high mortality. In contrast, lupus patients with a syndrome of acute reversible hypoxemia (SARH) have hypoxemia with normal chest x-ray films and a rapid response to corticosteroids. We present a case of biopsy-proven ALP with normal initial chest x-ray films, and a normal CT scan. We hypothesize that a continuum of vascular and parenchymal abnormalities may exist in the lungs of lupus patients. This case also illustrates the insensitivity of routine chest radiographs in demonstrating mild or early pneumonitis.

Radiographic Findings in HIV-Positive Patients With Sensitive and Resistant Tuberculosis

To facilitate early recognition of multi-drug resistant (MDR) Mycobacterium tuberculosis (MTB) disease in HIV-positive patients we evaluated the chest x-ray films of 72 patients in a tertiary care center in New York City. Thirty-three patients had sensitive MTB, 3 had single-drug resistant (SDR) MTB, and 36 patients had multi-drug resistant (MDR) MTB. All chest x-ray films were reviewed and correlated with drug sensitivities, additional diagnostic results, and clinical courses. There were no significant radiographic differences among the 3 groups on initial presentation (p > 0.05). Cavities were found in 12 patients, upper lobe disease in 23, lower lobe disease in 15, possible intrathoracic lymphadenopathy in 30, diffuse infiltrates in 12, pleural effusion in 13, and a miliary pattern in 3 patients. Normal chest x-ray films were found in ten patients. After 2 weeks of therapy, 20 out of 35 MDR-MTB patients developed new effusions, possible intrathoracic lymphadenopathy, or worsening infiltrates. With deterioration, the probability of MDR MTB was 95 percent in our case control study. Thus, it would be reasonable to adjust antituberculosis therapy in HIV-positive patients with deteriorating conditions shown on chest x-ray films after 2 weeks of therapy.

Retrospective analysis of the incidence of pulmonary disease in hypogammaglobulinemia

To determine the best predictors of chronic pulmonary disease in patients with hypogammaglobulinemia, we evaluated the clinical records, chest x-ray films, and pulmonary function tests of 10 patients with X-linked agammaglobulinemia (XLA) followed for a mean of 12.5 years, and 12 patients with common variable immunodeficiency (CVID) followed for a mean of 10.5 years. These patients, most of whom were treated with intramuscular gamma globulin and long-term oral antibiotics, had very few pneumonias after diagnosis. The patients with XLA had 0.10 pneumonias per treatment year, and the patients with CVID had 0.18 pneumonias per treatment year. Seven of the 10 patients with XLA had normal chest x-ray films 8 to 15 years after diagnosis, and none had bronchiectasis. Pulmonary disease was more common and more severe in the group with CVID, but five patients in this group also had normal chest x-ray films after long follow-up. In the entire group of 22 patients, nine of the 10 patients with abnormal chest x-ray films on most recent evaluation already had pulmonary disease at the initial visit ( p = 0.00002). These studies indicate that the best predictors of good pulmonary function in patients with hypogammaglobulinemia are early diagnosis and good compliance with gamma globulin replacement therapy and oral antibiotics.

Normalization of ventilation/perfusion relationships after liver transplantation in patients with decompensated cirrhosis: Evidence for a hepatopulmonary syndrome

To examine the effect of liver transplantation on the respiratory and cardiovascular functions, ventilation/perfusion relationships were determined by multiple inert gas elimination technique in six patients with end-stage liver disease 1 to 19 mo before and 2 to 6 mo after liver transplantation. Cardiac output and pulmonary vascular pressures were measured after catheterization of the pulmonary artery. All patients had normal spirometry and chest x-ray films before transplantation. PaO2 before transplantation was 78.8 +/- 7.4 mm Hg (range = 51.8 to 102.8 mm Hg). All patients had perfusion of poorly ventilated lung regions (low ventilation/perfusion relationships) varying from 3% to 19% of cardiac output (mean = 8.5% +/- 2.4% of cardiac output) and two patients had intrapulmonary shunting (3% and 20% of cardiac output). Measured and calculated PaO2 agreed closely, indicating absence of pulmonary diffusion abnormality, as well as of extrapulmonary shunting. After transplantation, PaO2 normalized in all patients, and both shunting and low ventilation/perfusion relationships disappeared. Cardiac output decreased from 9.1 +/- 1.4 to 6.6 +/- 0.5 L/min (p less than 0.05), and the pulmonary vascular resistance increased from 0.69 +/- 0.14 to 1.64 +/- 0.43 mm Hg/L/min (p less than 0.05). The systemic vascular resistance also increased (before = 8.7 +/- 1.0; after = 15.3 +/- 1.1 mm Hg/L/min; p less than 0.001). Normalization of respiratory and cardiovascular alterations, after liver transplantation, in patients with end-stage liver disease indicates that these changes have a direct functional relationship to the diseased liver. It is hypothesized that this is part of a "hepatopulmonary syndrome,' which in similarity to the hepatorenal syndrome disappears with improved liver function.

Pulmonary Involvement in Behcet's Syndrome

We present a case of Behcet's syndrome with unusual pulmonary manifestations. A woman presented five years previously with oral, genital and ocular lesions found on biopsy to be consistent with Behcet's syndrome. While on prednisolone, she complained of nonpleuritic chest pain. Clinical features of active Behcet's syndrome were absent. A previously normal chest x-ray film showed multiple intrapulmonary lesions. Laboratory abnormalities were consistent with findings seen in phases of disease activity. Bronchoscopy showed ulceration of the bronchial mucosa, but no evidence of opportunistic infection or neoplasia. Pulmonary angiography excluded vaso-occlusive abnormalities. A provisional diagnosis of pulmonary involvement with Behcet's syndrome was made and the patient responded to further immunosuppressive therapy.

Pneumothorax ? an unusual delayed presentation of congenital posterolateral diaphragmatic hernia

Pneumothorax as a delayed presentation of congenital posterolateral diaphragmatic hernia has not been described before. A normal chest X-ray film in the neonatal period does not preclude the possibility of a later presentation of congenital posterolateral diaphragmatic hernia.

Gallium Lung Scanning and Bronchoalveolar Lavage in Crocidolite-Exposed Workers

Gallium lung scanning is widely used to evaluate pulmonary inflammation in patients with interstitial lung disease but has not previously been reported in crocidolite-exposed workers. In order to characterize the pulmonary inflammation caused by crocidolite inhalation, GLS and BAL findings were related to chest x-ray film changes graded according to the ILO classification of roentgenograms of pneumoconioses. In individuals with roentgenographic evidence of asbestosis (CXR greater than or equal to 1/0, n = 15), 13 had a positive GLS and 13 had an abnormal BAL. In asbestos-exposed individuals with equivocal chest x-ray film changes (CXR 0/1, n = 12), six had a positive GLS and six had BAL changes (both GLS and BAL abnormal in three). In individuals with a normal chest x-ray film (CXR 0/0 n = 8), two had a positive GLS and two BAL changes (both abnormal in 1). These data demonstrate that most subjects with crocidolite-induced asbestosis have an abnormal GLS and BAL. In addition, many individuals with asbestos exposure and equivocal or no chest x-ray film changes have an abnormal GLS and/or BAL, suggesting the presence of active subclinical pulmonary inflammation in these individuals.

Bronchoalveolar Lavage in Extrapulmonary Sarcoidosis

Twenty-one patients presenting with extrapulmonary sarcoidosis, 20 patients with pulmonary sarcoidosis, and 12 healthy volunteers were investigated. They were evaluated for roentgenographic findings, as well as for immunologic marker expression of cells in bronchoalveolar lavage (BAL) fluid. The patients presenting with extrapulmonary sarcoidosis could be divided in two groups: nine of 21 (43 percent) presented with a stage 1 or stage 2 chest x-ray film, while 12 of 21 (57 percent) had no chest x-ray film abnormalities (stage 0). In all three groups of sarcoidosis patients, a significant increase of CD3+ T lymphocytes in the BAL fluid was found as compared to the healthy volunteers. However, the percentages of T lymphocytes in BAL fluid of patients with extrapulmonary sarcoid lesions and a normal (stage 0) chest x-ray film was significantly lower as compared to patients with extrapulmonary sarcoidosis and an abnormal (stage 1, 2) chest x-ray film, while the latter patient group did not differ from the patients with pulmonary sarcoidosis. This suggests that in patients with extrapulmonary sarcoidosis, a gradual progression of the T cell alveolitis may occur. Furthermore, these data indicate that a marked discrepancy between chest x-ray film abnormalities and the presence of an alveolitis as determined by immunologic marker analysis exists in more than 50 percent of the patients with extrapulmonary sarcoidosis.

Hypoxemia in Acute Pulmonary Embolism

Most patients with severe, acute pulmonary embolism (PE) have arterial hypoxemia. To further define the respective roles of ventilation to perfusion (VA/Q) mismatch and intrapulmonary shunt in the mechanism of hypoxemia, we used both right heart catheterization and the six inert gas elimination technique in seven patients with severe, acute PE (mean vascular obstruction, 55 percent) and hypoxemia (mean PaO2, 67 +/- 11 mm Hg). None had previous cardiopulmonary disease, and all were studied within the first ten days of initial symptoms. Increased calculated venous admixture (mean QVA/QT 16.6 +/- 5.1 percent) was present in all patients. The relative contributions of VA/Q mismatching and shunt to this venous admixture varied, however, according to pulmonary radiographic abnormalities and the time elapsed from initial symptoms to the gas exchange study. Although all patients had some degree of VA/Q mismatch, the two patients studied early (ie, less than 48 hours following acute PE) had normal chest x-ray film findings and no significant shunt; VA/Q mismatching accounted for most of the hypoxemia. In the others a shunt (3 to 17 percent of cardiac output) was recorded along with radiographic evidence of atelectasis or infiltrates and accounted for most of the venous admixture in one. In all patients, a low mixed venous oxygen tension (27 +/- 5 mm Hg) additionally contributed to the hypoxemia. Our findings suggest that the initial hypoxemia of acute PE is caused by an altered distribution of ventilation to perfusion. Intrapulmonary shunting contributes significantly to hypoxemia only when atelectasis or another cause of lung volume loss develops.

Spontaneous Pneumothorax: A Complication of Lung Cancer?

Among 338 adults (258 men and 80 women) presenting with spontaneous pneumothorax, there were six men with lung cancer: five squamous cell carcinoma and one oat cell carcinoma. Pneumothorax led to the diagnosis in five cases and the remaining occurred as a complication of known neoplastic disease. The average age was 67 years. We analyze these six cases, along with 46 others from the literature. In patients less than 40 years old with normal chest x-ray film findings after lung expansion, further investigation for neoplastic disease is not justified. However, heavy smoking, chronic bronchitis, bullous emphysema and incomplete lung expansion after chest drainage in patients over 40 years old are indications for cancer screening through sputum cytologic study, bronchoscopic examination and surgical exploration. The occurrence of a pneumothorax neither alters the treatment of the underlying disease nor modifies the one-year prognosis. Five-year survival is nil, suggesting that lung cancers present as pneumothorax at an advanced stage of disease.

Radiologic Findings in Farmer's Lung: Prognosis and Correlation to Lung Function

We classified the radiologic findings of 93 patients with acute or subacute farmer's lung (FL) disease by type and severity of the change in chest x-ray film. Acute radiologic changes, further divided as nodular, ground-glass, or striated patchy opacities, were found in 78/93 patients at the first evaluation; 11 showed chronic changes (radiologic "fibrosis"), which persisted unchanged throughout the follow-up period; and four initially had a normal chest x-ray film. Patients were followed up 23 months on an average. The more severe the radiologic change at the first evaluation, the more impaired the diffusing capacity (Dsb). Severe radiologic changes disappeared more slowly than the less severe ones. The differences in the initial pulmonary function values between the two groups disappeared during the follow-up. The type of acute change did not predict the recovery of respiratory performance. Treatment with oral corticosteroids did not affect the outcome of lung function or appearance of chronic changes, although corticosteroids seemed to hasten the disappearance of diffuse opacities. At the final evaluation, the chest x-ray film was normal in 55/93 patients. Chronic changes were detected in 38 patients. Severe radiologic appearance and striated patchy opacities predisposed to development of chronic changes.

Role of Fiberoptic Bronchoscopy in Patients with Hemoptysis and a Normal Chest Roentgenogram

We reviewed the charts of 48 consecutive patients who had fiberoptic bronchoscopy performed in the evaluation of hemoptysis with a normal chest roentgenogram. Fiberoptic bronchoscopy provided a diagnosis other than endobronchial inflammation in only four patients--benign fibromuscular polyp in one patient, Mycobacterium tuberculosis in 1 patient, and carcinoma in two others. A literature review revealed an overall 3 percent incidence of bronchogenic carcinoma in patients with hemoptysis and normal findings on chest roentgenogram. Other than abnormal findings on chest roentgenogram, risk factors for carcinoma in patients with hemoptysis include: (1) age greater than 40; (2) significant smoking history; and (3) duration of hemoptysis for longer than one week. We concluded that in patients with hemoptysis and normal chest x-ray film findings, routine fiberoptic bronchoscopy may not always be indicated to rule out malignancy.

Five-year findings of the Hypertension Detection and Follow-up Program. Prevention and reversal of left ventricular hypertrophy with antihypertensive drug therapy. Hypertension Detection and Follow-up Program Cooperative Group.

The Hypertension Detection and Follow-up Program followed 10,940 hypertensive adults for 5 years. Participants were monitored with electrocardiograms (ECGs) and chest x-ray films. Changes in ECG and cardiothoracic ratio were compared between stepped car and the referred care groups. In those with tall R wave by ECG at baseline, who survived the 5-year follow-up, incidence of left ventricular hypertrophy (LVH) by ECG criteria was 4.1% in the stepped care group and 8.6% in the referred care group (p less than 0.01). In those participants with ECG evidence of tall R wave or LVH at baseline, the rate of regression toward normal was 54.3% in the stepped care group and 42.9% in the referred care group (p less than 0.01). Reversal of enlarged cardiac silhouette on chest x-ray film (cardiothoracic ratio greater than or equal to 0.5) occurred in 47% of the stepped care group and in 38% of the referred care group (p less than 0.01). These results indicate that the use of systematic antihypertensive therapy to achieve goal blood pressure reduces the incidence of LVH enlarged cardiac silhouette in adults with hypertension. In addition, it was found that antihypertensive treatment tends to reverse previous LVH or high cardiothoracic ratios toward a normal ECG and chest x-ray film pattern among hypertensive subjects. These findings are of particular importance because these indices are predictors of poor prognosis among untreated patients with hypertension.

Boilermakers?? Bronchitis

Severe respiratory tract irritation occurred in at least 74 of 100 boilermakers who were exposed to high levels of vanadium pentoxide fume during oil-to-coal conversion of a utility company power plant in a rural area of western Massachusetts. Many were welders working in confined areas with inadequate ventilation. Most frequent symptoms were productive cough, sore throat, dyspnea on exertion, and chest pain or discomfort. The illness was severe enough to cause 70 workers to consult physicians and most of them to lose time from work (median, five days). Wheezing (in 39%) was the most frequent finding on physical examination. Mild hypoxemia was noted in several workers; most (72%) had normal chest x-ray films. Expiratory flow rate over the middle 50% of the forced vital capacity was the pulmonary function test most remarkably affected (median, 57% of predicted for 24 workers tested). The Occupational Safety and Health Administration documented levels of vanadium pentoxide fume at or above the permissible exposure limit in all eight air samples taken from inside the boiler; it cited the company for inadequate mechanical ventilation and an inadequate respiratory protection program for workers. The report of this outbreak may help prevent future problems by drawing attention of physicians, workers, and managers to the potential pulmonary hazards in power plant conversion.

Total Respiratory Pressure-Volume Curves in the Adult Respiratory Distress Syndrome

To assess the value of measuring compliance in the adult respiratory distress syndrome, sequential pressure-volume curves were obtained in 19 patients with this syndrome. Analysis of the pressure-volume curves allowed separation of the patients into the following four groups: (1) group 1 (n = 6), normal compliance measured during deflation, little hysteresis, and no inflection in the ascending limb of the pressure-volume tracing; (2) group 2 (n = 8), normal compliance during deflation, increased hysteresis, and presence of an inflection; (3) group 3 (n = 10), decreased compliance during deflation, marked hysteresis, and presence of an inflection; and (4) group 4 (n = 10), reduced compliance during deflation, no increased hysteresis, and no inflection. These patterns were correlated with the stage of the adult respiratory distress syndrome and to the pattern of the chest x-ray film. Group 2 corresponds to the initial stage of the syndrome and to pure alveolar opacities on the chest x-ray film. Group 3 is seen later in the course of the syndrome and corresponds to mixed alveolar and interstitial opacities. Group 4 corresponds to patients with end-stage adult respiratory distress syndrome (two weeks) and a predominant interstitial pattern on the chest x-ray film. Group 1 corresponds to a nearly normal chest x-ray film and to recovery.

Mucous Plugging Simulating Pulmonary Embolism in Patients with Quadriplegia

Two quadriplegic patients suddenly lost consciousness and were found to have an elevated alveolar-arteriolar oxygen gradient. Their chest x-ray films were normal. Perfusion scintiscans of their lungs showed large areas with markedly reduced or absent perfusion. Ventilation scintiscans demonstrated absent or decreased ventilation to the hypoperfused areas, suggesting mucous plugging. In quadriplegic subjects who have an ineffective cough, acute mucous plugging can produce the sudden onset of hypoxia with essentially normal chest x-ray films, thus mimicking acute pulmonary embolism.