Presentation
Fever and right chest pain for one month. Productive cough for one week.
Patient Data
Right diaphragmatic contour is not clearly seen.
Ill-defined opacity in right lower zone with air fluid level.
Blunted right costophrenic angle.
Right subdiaphragmatic abscess with air-fluid level (9 x 7 x 6 cm).
Evidence of right diaphragmatic discontinuity in the middle portion with extension of the abscess to the right lung lower lobe.
Air space consolidation/collapse of right lung lower lobe with evidence of lung necrosis.
Nodular opacities with tree in bud appearance throughout both lungs
Prominent mediastinal and hilar lymph nodes.
Case Discussion
The imaging features are typical for subdiaphragmatic abscess formation with diaphragmatic fistulation to right lung lower lobe and associated right lung lower lobe necrosis/collapse and feature of active lung infection.
No obvious cause for the subphrenic abscess was clinically detected, such as perforation of a hollow viscus, intraabdominal inflammatory process, trauma or prior surgery.
One possibility could be a primary chest infection (lobar pneumonia) causing diaphragmatic injury and subphrenic abscess, however, the vice versa can also be acceptable: idiopathic subphrenic abscess with diaphragmatic injury and right lower lobar secondary infection.