A 60-year-old female patient was admitted to the medical ward with complaints of persistent dry cough for 12 months and hoarseness of voice for 6 months. She had lost 18 kg of weight over the past 4 months. On examination, the patient was thin. The trachea was shifted to the right side and there was a dull note on percussion over the right upper zone anteriorly. Tubular bronchial breath sounds were heard in the same area. Her chest radiograph done on admission is shown in Figure 1.
Figure 1.
Question
Describe the chest radiographic findings.
What is the likely diagnosis in this patient?
What further investigations would you undertake to confirm the diagnosis?
Answer
There is a diffuse opacity in the right upper zone with a small area of hyperluscency within it. No air bronchogram is seen. The trachea is significantly shifted to the right side. The transverse fissure is pulled upwards. The right hilum is enlarged. All these radiographic findings are suggestive of collapse of the right upper lobe1,2 with a small area of necrosis medially, along with prominent right hilar lymph nodes.
In view of the fact that the patient has a persistent dry cough, hoarseness of voice, significant weight loss3 and clinical and radiographic features suggestive of right upper lobe collapse with right hilar enlargement, the likely diagnosis is bronchogenic carcinoma with proximal endobronchial obstruction.
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Further investigations to be undertaken, include:
Sputum for cytology.
High-resolution CT scan of the chest,4 and CT-guided percutaneous biopsy, if scan is suggestive of a lung parenchymal mass located peripherally.
Magnetic resonance imaging (MRI) of the chest.5
Fibreoptic bronchoscopy, if an endobronchial tumour or lesion, endobronchial foreign body or a proximal parenchymal lung tumour is suspected. In these cases, an endobronchial biopsy, bronchoalveolar lavage or a transbronchial lung biopsy can be carried out, respectively.
Acknowledgement
The author wishes to thank Dr. K.Y. Loh, Associate Professor in Family Medicine, International Medical University Clinical School, Seremban, Malaysia, for his kind help in the preparation of the image used in this paper.
References
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