A Hole in the Diaphragm: Mystery lung disease.

A Hole in the Diaphragm: Mystery lung disease.


From Mike:

A Hole in the Diaphragm

Mystery lung disease.

I thought this insight might be helpful as there are many medical school teachers and medical students and doctors on my email list.

This is an interesting case of a hole in the diaphragm (right side) with lung tissue obstruction right above it.

Video x-rays I have watched show the hole as being a weakened, shrunken portion of the diaphragm. Whenever the diaphragm weakens it loses its ability to squeeze the sponge of the lungs right above it. Then debris collects. The lungs are a lot like a kitchen sponge that you need to squeeze to allow water to enter then squeeze again to force the debris out of the sponge. 

A 44-year-old man with acute myelogenous leukemia presented with mild pleuritic chest discomfort of several days' duration and 1 episode of blood-tinged sputum. In general, he felt well and denied shortness of breath. Vital signs were normal, and he did not have a fever. Physical examination, including chest examination, was normal.

The patient had been diagnosed with leukemia 2 months previously, and induction therapy had been given successfully. Two weeks prior to this current presentation, high-dose cytarabine (3g/m2 every 12 hours for 3 days) was given as consolidation chemotherapy. His medications at this time were ipratropium inhaler, acetaminophen, prochlorperazine, venlafaxine, fluvastatin, naproxen, and allopurinol.

His WBC count was 500 × 106/L, with an absolute neutrophil count of 100 × 106/L. Chest radiograph (Fig. 1) showed interstitial infiltrates bilaterally. Sputum was insufficient for examination. Bronchoalveolar lavage revealed no organisms on Gram's or acid-fast stain. Direct fluorescent antibody testing for Pneumocystis carinii and Legionella pneumophila was negative. Cultures were obtained.

What is your diagnosis?

What is your suggested approach?

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