A 68-year-old woman had previously undergone multiple surgical procedures for peptic ulcer disease. She developed a recurrent upper gastrointestinal hemorrhage and underwent laparotomy at a local hospital. When this procedure did not reveal the source of bleeding, the patient was transferred to our hospital in hypovolemic shock. A left thoracotomy was performed, and the aorta was crossclamped for control of hemorrhage. Laparotomy revealed a bleeding gastroesophageal ulcer. The ulcer was oversewn, and the patient was taken to the ICU. A week after the operation, the patient developed signs of peritonitis and sepsis. An abdominal CT documented extravasation of gastrointestinal contrast, thus supporting the clinical diagnosis of colonic perforation. After colostomy and drainage, the patient was transiently stabilized, but later deteriorated. Abdominal CT, routine cultures, and multiple portable chest roentgenograms were nondiagnostic.
The interpretation of the initial portable chest x-ray film, performed with the patient supine because of the recent surgery, demonstrated a globular heart, apparently a sizeable left pleural effusion, left lower lobe atelectasis, and a left basal thoracostomy tube (Fig 4). Again, variance between the clinical course and the patients roentgenogram, plus nondraining left thoracostomy tube, suggested compartmentalization of fluid or empyema, and a chest CT was obtained. The chest CT confirmed a sizeable pericardial effusion, as well as left sided pneumothorax, an empyema cavity in the left pleural space, and unsuspected atelectasis in the right lobe. Compensatory left lower lobe collapse was also present (Fig 5). The fluid collections were drained with appropriately placed thoracostomy tubes. The patient developed multisystem failure due to sepsis and died three weeks later. Click Here
A 46-year-old obese white man was admitted to the ICU because of respiratory failure and sepsis which developed after a para-aortic lymphadenectomv for embryonal carcinoma of the right testicle. An orchiectomy had been performed three weeks earlier without complications. At that time results of the chest roentgenogram, the chest and abdominal CT scans, and the lymphographic study were normal. The patient was receiving actinomycin-D, 0.5 and 1.0 g on alternative days. On the day of admission, the patient required tracheal intubation, mechanical ventilation with 12 cmH20 positive end-expiration pressure (PEEP), and 50 percent oxygen. The portable supine chest roentgenogram (Fig 6) demonstrated right lower lobe atelectasis and right pleural effusion, slight cardiomegaly, and perihilar haze. Chest physical therapy was performed in an attempt to reinflate the right lower lobe atelectasis. The subsequent day’s portable chest roentgenogram (Fig 7) showed worsening of the consolidative pattern in the left lung with little change on the right; hence, a chest CT to further evaluate the status of the underlying lung was performed. Chest CT (Fig 8) demonstrated posterior lung abscesses with cavitation below the dome of the diaphragm on the right. The disease on the left was unsuspected and may have been precipitated or exacerbated by the chest physical therapy. An antibiotic-resistant strain of Pseudomonas aeruginosa was cultured from a tracheal aspirate. The administration of appropriate antimicrobial therapy was associated with slow recovery and discharge from the hospital three months after admission to the ICU.
Figure 4, Case 2. AP chest roentgenogram done supine demonstrates a globular heart, left pleural effusion (arrowheads) and atelectasis in the left lower lobe.
Figure 5, Case 2. Upper, CT a lung window demonstrates a pneumothorax (curved arrow) and basically no aerated lung behind the plane of the left main bronchus. A loculated pleural effusion and compensatory lower lobe atelectasis are present posteriorly. Lower.; CT at mediastinal window at the level of the left atrium demonstrates the pericardial fluid (white arrow) and an air fluid level (white arrowhead) loculated in the left pleural space inferiorly associated with left lower lobe atelectasis (black arrow).
Figure 6, Case 3. Portable supine AP roentgenogram demonstrates opacity of the lower half of the right hemithorax, preservation of the right heart margin, ill defined right perihilar haze with central lucency, and areas of patchy consolidation in the left lung.
Figure 7, Case 3. This AP semi-erect portable chest roentgenogram following physiotherapy demonstrates increase in the left multifocal consolidative areas and persistent obliteration of the right lower hemithorax.
Figure 8, Case 3. This CT at the dome of the right hemidiaphragm demonstrates two large lung abscesses on the right and an elevated anterior portion of the right hemidiaphragm. Left lower lobe consolidation is also identified posteriorly (arrow).