The CXR shows a mass in the left upper lobe (Fig. 76.2), representing a primary lung cancer. In addition, the left hemidiaphragm is elevated such that it is higher than the right. Normally the right hemidiaphragm is 1-2 cm higher than the left. The left hemidiaphragm elevation here is likely due to left phrenic nerve palsy, probably due to mediastinal lymph node metastases. Other causes of an elevated hemidiaphragm include recent cardiac bypass surgery, trauma, and previous herpes zoster involving the phrenic nerve. The commonest cause, however, is idiopathic phrenic nerve palsy.
Case 77. This middle-aged male had low-grade fever of one month's duration associated with productive cough and loss of weight. His CXR is shown (Fig. 77.1).
CASE 77 RIGHT LOWER LOBE CONSOLIDATION DUE TO TUBERCULOSIS IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) HOST
The patient had subacute fever and the CXR shows air bronchograms in the right lower zone. There is loss of outline of the right hemidiaphragm (Silhouette sign) confirming right lower lobe consolidation (Fig. 77.2). His sputum turned out to be positive on acid-fast bacillus (AFB) smear confirming that he had active pulmonary tuberculosis. He also reported frequent visits to commercial sex workers and his HIV serology was positive. There are two forms of TB in HIV patients. One form, occurring in early HIV disease, is no different from that in a non-immuno-compromised host with classic upper lobe cavitary disease. In patients with late stage HIV disease, CXR presentation is atypical with less preponderance of cavitation, less upper lobe disease, and greater predominance of thoracic lym-phadenopathy and pleural effusion. All patients with tuberculosis should be investigated for HIV infection.
Case 78. This patient was asymptomatic (Fig. 78.1). The CXR is shown.
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