Submitted by Dr LAU Chun Wing Arthur, Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
A F/ 80 lady with diabetes mellitus and hypertension was admitted for SOB with cough and sputum and orthopnoea. There was no fever and other constitutional symptoms, but she was noticed to have high oxygen requirement and so was transferred to the ICU for close monitoring. ABG showed compensated type II respiratory failure and high WCC increased. Serial CXRs were taken.
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CT thorax was done.
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CT thorax report: Elevation of left hemidiaphragm with herniation of stomach and part of colon. Mediastinal shift towards right side is noted. Areas of patchy consolidation are seen in right lower lobe. Mild left basal atelectatic change is seen. Mild bilateral basal pleural effusion is noted. Main bronchi are patent. No definite mediastinal mass is noted. A small hyperdense focus, measures approximately 0.8cm in size, is seen in right lobe of liver, probably due to a small calcified granuloma. No large gall stone is seen. Bile ducts are not dilated. Spleen and pancreas are not enlarged with no focal lesion seen. Small hypodense lesions, measure up to 2.6cm in size, are seen in both kidneys, probably due to cysts. No evidence of hydronephrosis is seen in both kidneys. Adrenals are not enlarged. No ascites is seen in upper abdomen. IMPRESSION: Elevation of left hemidiaphragm with herniation of stomach and part of colon causing mediastinal shift towards right side, patchy consolidation in right lower lobe, bilateral basal pleural effusion with left basal atelectatic changes, small calcified granuloma in right lobe of liver, bilateral renal cysts.
Fluoroscopy: left hemidiaphragmatic palsy, with paradoxical movement
Echocardiogram: some diastolic dysfunction, LV systolic function normal
Exploratory thoracotomy with plication of L hemidiaphragm were done, operative finding: no diaphragmatic hernia, flaccid overstretched diaphragm raised to lower pleural cavity seen (due to palsy), normal underlying lung
Diagnosis
Flaccid overstretched diaphragm due to left hemidiaphragmatic palsy, complicated by chest infection
Discussion
In retrospect, orthopnoea was caused by the diaphragmatic palsy.
Causes of unilateral diaphragmatic palsy: student BMJ
Diaphragm development images and causes of hernia, eventration and congenital absence: Vesalius
| Bochdalek type of diaphragmatic hernia | = failure of closure of the pleruoperitoneal canal, usu on L side |
| Morgagni type of diaphragmatic hernia | = widening of the vascular channel between the sternal and costal muscle slips, usu on R side |
| Eventration of the diaphragm | = failure of muscle fibre ingrowth into the membranous diaphragm |
| Congenital absence | = a wide failure of fusion of the diaphragmatic membrance components |