Sickle cell anaemia on chest radiograph


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Lungs and pleural spaces are clear. Cardiomediastinal contours are normal. The bones are diffusely sclerotic and there are H-shaped vertebral bodies in keeping with sickle cell anaemia.

Chilaiditi’s sign.


A 79-year-old man presented with symptoms and signs of upper respiratory tract infection; he had a history of permanent pacemaker implantation. An upright postero-anterior chest radiograph showed a raised right hemidiaphragm delineated by subdiaphragmatic air. Unlike free air, which forms an uninterrupted crescent-shaped subdiaphragmatic radiolucency, this radiograph showed a haustral pattern of subdiaphragmatic lucency, overlapping the upper border of the liver shadow. On examination, clinical findings suggesting acute abdomen from rupture of a hollow viscus were absent and there was no recent history of abdominal surgery to account for the presence of subdiaphragmatic air.

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The visualisation of a gas filled transverse colon lumen interpositioned between the right hemidiaphragm and the liver on a chest film is called Chilaiditi’s sign. A CT scan may confirm these anatomical relations. In our patient’s radiograph, the haustral pattern of air was indicative of colonic origin, and the continuity of the subdiaphragmatic air was broken up by the shadow of the vertical plicae semilunares of the colon. Chilaiditi’s sign was first described in 1910 by Demetrious Chilaiditi and it is an incidental radiographic finding. This sign can be mistaken for pneumoperitoneum and can lead to needless surgical intervention. Our patient was treated only for his upper respiratory tract infection.

Source: Lancet

Gastrobronchial fistula.


A 67-year-old man presented with left anterior chest pain of sudden onset. On admission, chest radiography showed left lower lobe infiltrates.

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8 days later, chest radiography showed a cavitating lesion, consistent with a pulmonary abscess. CT of the chest revealed a pulmonary abscess in the left lower lobe. Suspecting an oesophagobronchial fistula, we did a barium contrast study, which showed a passage from the gastric fundus to the pulmonary abscess (figure). Oesophagogastroduodenoscopy confirmed the presence of a fistula in the gastric fundus; gastric contents were seen to enter the fistula. The fistula, and the left lower lobe to which it was adherent, were surgically resected, and the diaphragm was repaired. The patient’s recovery was uneventful.

Source: Lancet

Low C-reactive protein levels helped rule out pneumonia.


  Acute bronchitis is managed expectantly, and pneumonia is managed with antibiotics. However, accurately distinguishing these conditions, based on history and physical examination alone, is difficult. Although chest x-ray can distinguish acute bronchitis from pneumonia, it is expensive, exposes patients to radiation (often unnecessarily), and is unavailable in some settings. In this European study, investigators determined whether measuring blood C-reactive protein (CRP) and procalcitonin concentrations, in addition to history and physical examination, improved diagnostic accuracy. Among 2820 adults (mean age, 50) who presented with cough to primary care practices, chest x-ray confirmed pneumonia in 140 patients (5%). The optimum combination of history and examination findings for pneumonia was absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever. Adding CRP level as a continuous variable resulted in significantly improved ability to predict pneumonia (multivariate odds ratio, 1.2 per 10 mg/L rise in CRP concentration). Adding CRP as a dichotomized variable (>30 mg/L as high-risk for pneumonia) yielded similar results. Of 665 patients with low probability (<2.5%) for pneumonia based on history and examination findings only, 11 (2%) actually had pneumonia. Adding CRP level reclassified 891 additional patients into the low-risk group (total, 1556); of these, 31 (2%) actually had pneumonia. Procalcitonin added no diagnostic information. Comment: In this study, adding blood CRP concentration to history and examination findings improved diagnostic accuracy for pneumonia — mainly by ruling out the infection. Of course, this approach depends on the availability of timely point-of-care CRP testing.   Source:  Journal Watch General Medicine