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roentgenogram of the month
roentgenogram otlhe month Shifting Granuloma: A Sign of Lobar Collapse* R. Tirrwthy Webb, M.D .; ]. Neal Beaton, M.D .; Frank]. Wilson, Jr., M.D.; and F. Charles Hiller, M.D., F.C.C.P.
he patient is a 57-year-old woman with a history of T childhood asthma which resolved and remained quiescent until ten years prior to the present admission when she again began to experience asthmatic episodes requiring therapy with methylxanthine and bet~ agonist bronchodilators. She had had several previous hospitalizations for control of acute exacerbations. She presented to the emergency room because of a several-hour history of dyspnea, tachypnea and cough productive of whitish sputum. Physical examination at that time demonstrated a 30 mm Hg; paradoxic pulse, slight intercostal retractions, inspiratory and expiratory wheezes without crackles, and a sinus tachy*From the Pulmonary Division, Department oflnternal Medicine, University of Arkansas College of Medicine, Little Rock. Reprint requests: Dr: Hiller, Pulmonary Division, University of Arkansas for Medical Sciences , LiHle Rock 72205
FIGURE
1
cardia. Arterial blood gas levels obtained at that time showed Pa0 2 , 64 mm Hg; PaC0 2 , 38 mm Hg; and pH, 7.38. The chest radiograph (Fig 1) demonstrated hyperinflation without infiltrates. She improved only slightly with bronchodilator therapy while in the emergency room, and was admitted for further treatment. Progressive hypoxia and worsening acidosis necessitated her transfer to the intensive care unit and endotracheal intubation. Initially, extremely high pressures (80-90 mm Hg) were required for adequate ventilation. She developed right pneumothorax, pneumomediastinum, and subcutaneous emphysema necessitating chest tube placement. Longitudinal chest radiographs made while in the intensive care unit are shown (Fig 1-3). A radiograph two weeks following discharge is also shown (Fig 4).
FIGURE
2
CHEST I 85 I 4 I APRIL, 1984
559
Diagnosis: Left lower lobe atelectasis with shifting granuloma as a clue to atelectasis Atelectasis and loss of lung volume may occur as a resorptive process secondary to alveolar or bronchial airway obstruction, or may occur passively secondary to an expanding space occupying process, ie, intrapulmonary mass, bullae, hydrothorax or pneumothorax. Other etiologies include pulmonary fibrosis and surfactant abnormalities causing microatelectasis. 1 Displacement of the interlobar fissures is the only direct sign of loss of lung volume. 2 Indirect signs are also well recognized and include hilar displacement, mediastinal displacement, hemidiaphragm elevation, increased local density, compensatory overinflation, rib approximation, and absence of air bronchograms, the latter especially pertinent in atelectasis secondary to airway obstruction and subsequent air absorption. 2 An additional sign, shifting granuloma, 3 as demonstrated in this series of x-ray films, may also be a useful early diagnostic marker of atelectasis. Recognition of major fissure displacement, especially with minimal atelectasis, is often difficult without a lateral chest roentgenogram which is usually not taken when portable films are made in intensive care units. Shifting granuloma is also a direct sign, and in that respect, corresponds to interlobar fissure displacement. The shifting granuloma sign often may be seen easily on the portable A-P view. The apparent medial shift of the peripheral calcified granuloma in this presentation is demonstrated (Fig 2) before the classic findings of the left lower lobe collapse eventually ensue, ie, silhouetting of the diaphragm and a triangular shaped retrocardiac shadow (Fig 3). • Though useful only in patients with appropriately placed calcifications, shifting pulmonary calcifications offer an increased assurance of loss of lung volume. Likewise, return of the granuloma to its original position (Fig 4) is assurance of resolution of atelectasis. Such assurance is particularly helpful when radiographic findings are equivocal, such as often occurs in the upper lobe collapse, or when a basilar pulmonary density is seen along with a pleural effusion . Recognition of this sign may result in earlier therapeutic measures for prevention of a major pulmonary collapse.
FIGURE
3
FIGURE
4
REFERENCES
Robbins LL, Hale CH . The roentgen appearance of lobar and segmental collapse of the lung: a preliminary report. Radiology 1945;44:107-14 2 Fraser RC, Pare JAP. Diagnosis of diseases of the chest. Philadelphia: W BSaunders, 1970; 379
560
3 Rohlfing BM. The shifting granuloma: An internal marker of atelectasis. Radiology 1977; 123:283-85 4 Clay J, Palayew MJ. Unusual pattern ofleft lower lobe atelectasis. Radiology 1981; 141:331-33
Shifting Granuloma (Webb
et al)
he patient is a 57-year-old woman with a history of T childhood asthma which resolved and remained quiescent until ten years prior to the present admission when she again began to experience asthmatic episodes requiring therapy with methylxanthine and bet~ agonist bronchodilators. She had had several previous hospitalizations for control of acute exacerbations. She presented to the emergency room because of a several-hour history of dyspnea, tachypnea and cough productive of whitish sputum. Physical examination at that time demonstrated a 30 mm Hg; paradoxic pulse, slight intercostal retractions, inspiratory and expiratory wheezes without crackles, and a sinus tachy*From the Pulmonary Division, Department oflnternal Medicine, University of Arkansas College of Medicine, Little Rock. Reprint requests: Dr: Hiller, Pulmonary Division, University of Arkansas for Medical Sciences , LiHle Rock 72205
FIGURE
1
cardia. Arterial blood gas levels obtained at that time showed Pa0 2 , 64 mm Hg; PaC0 2 , 38 mm Hg; and pH, 7.38. The chest radiograph (Fig 1) demonstrated hyperinflation without infiltrates. She improved only slightly with bronchodilator therapy while in the emergency room, and was admitted for further treatment. Progressive hypoxia and worsening acidosis necessitated her transfer to the intensive care unit and endotracheal intubation. Initially, extremely high pressures (80-90 mm Hg) were required for adequate ventilation. She developed right pneumothorax, pneumomediastinum, and subcutaneous emphysema necessitating chest tube placement. Longitudinal chest radiographs made while in the intensive care unit are shown (Fig 1-3). A radiograph two weeks following discharge is also shown (Fig 4).
FIGURE
2
CHEST I 85 I 4 I APRIL, 1984
559
Diagnosis: Left lower lobe atelectasis with shifting granuloma as a clue to atelectasis Atelectasis and loss of lung volume may occur as a resorptive process secondary to alveolar or bronchial airway obstruction, or may occur passively secondary to an expanding space occupying process, ie, intrapulmonary mass, bullae, hydrothorax or pneumothorax. Other etiologies include pulmonary fibrosis and surfactant abnormalities causing microatelectasis. 1 Displacement of the interlobar fissures is the only direct sign of loss of lung volume. 2 Indirect signs are also well recognized and include hilar displacement, mediastinal displacement, hemidiaphragm elevation, increased local density, compensatory overinflation, rib approximation, and absence of air bronchograms, the latter especially pertinent in atelectasis secondary to airway obstruction and subsequent air absorption. 2 An additional sign, shifting granuloma, 3 as demonstrated in this series of x-ray films, may also be a useful early diagnostic marker of atelectasis. Recognition of major fissure displacement, especially with minimal atelectasis, is often difficult without a lateral chest roentgenogram which is usually not taken when portable films are made in intensive care units. Shifting granuloma is also a direct sign, and in that respect, corresponds to interlobar fissure displacement. The shifting granuloma sign often may be seen easily on the portable A-P view. The apparent medial shift of the peripheral calcified granuloma in this presentation is demonstrated (Fig 2) before the classic findings of the left lower lobe collapse eventually ensue, ie, silhouetting of the diaphragm and a triangular shaped retrocardiac shadow (Fig 3). • Though useful only in patients with appropriately placed calcifications, shifting pulmonary calcifications offer an increased assurance of loss of lung volume. Likewise, return of the granuloma to its original position (Fig 4) is assurance of resolution of atelectasis. Such assurance is particularly helpful when radiographic findings are equivocal, such as often occurs in the upper lobe collapse, or when a basilar pulmonary density is seen along with a pleural effusion . Recognition of this sign may result in earlier therapeutic measures for prevention of a major pulmonary collapse.
FIGURE
3
FIGURE
4
REFERENCES
Robbins LL, Hale CH . The roentgen appearance of lobar and segmental collapse of the lung: a preliminary report. Radiology 1945;44:107-14 2 Fraser RC, Pare JAP. Diagnosis of diseases of the chest. Philadelphia: W BSaunders, 1970; 379
560
3 Rohlfing BM. The shifting granuloma: An internal marker of atelectasis. Radiology 1977; 123:283-85 4 Clay J, Palayew MJ. Unusual pattern ofleft lower lobe atelectasis. Radiology 1981; 141:331-33
Shifting Granuloma (Webb
et al)