Right hemithorax white-out: pleural effusion

Case contributed by Roberto Schubert
Diagnosis almost certain

Presentation

Dyspnea

Patient Data

Age: 65 years
Gender: Female

Chest x-ray

x-ray

Frontal and lateral radiographs of the chest demonstrate complete white out of the right hemithorax. There is evidence of positive mass effect upon the mediastinum which is shifted towards the left (including the trachea), with leftward bowing of the azygo-esophageal recess. The right ribs are also splayed. 

On lateral projection only one pleural cavity is visible (the left one). 

Annotated images

Annotated image

Signs of positive mass effect on the right include: 

  1. shift of the mediastinum and trachea (blue) to the left
  2. leftward bowing of the azygo-esophageal recess (yellow)
  3. splaying of the ribs on the right (red)

On the lateral film one knows that the affected side is the right because: 

  1. the aortic arch is visible (orange)
  2. the visible hemidiaphragm and pleural surface (green) abuts the posterior border of the heart (IVC)
  3. gastric air bubble (purple) abuts the visible hemidiaphragm

Note that the film has been obtained with the right side against the film (opposite to normal) and thus it is the left hemidiaphragm which is magnified. 

Case Discussion

This case illustrates the typical appearance of a very large pleural effusion (in this case due to a pulmonary malignancy) and demonstrates the signs which enable it to be confidently distinguished from collapse or consolidation of the right lung. 

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