CASE SERIES


https://doi.org/10.5005/jp-journals-11010-1072
Indian Journal of Respiratory Care
Volume 12 | Issue 4 | Year 2023

Divulging the Pandora Box: A Case Series of Abnormal Chest X-ray in Asymptomatic Patients


Jerin Paul P1https://orcid.org/0009-0007-3247-914X, Suresh Kumar D2https://orcid.org/0000-0001-7528-7788, Srinivasan R3

1–3Department of Respiratory Medicine, Meenakshi Medical College and Research Institute, MAHER University, Kanchipuram, Tamil Nadu, India

Corresponding Author: Jerin Paul P, Department of Respiratory Medicine, Meenakshi Medical College and Research Institute, MAHER University, Kanchipuram, Tamil Nadu, India, Phone: +91 9442718980, e-mail: jerinpaul15@gmail.com

Received: 27 June 2023; Accepted: 16 October 2023; Published on: 18 January 2024

ABSTRACT

Chest X-ray is a rapid, noninvasive, and easily accessible diagnostic tool to diagnose chest diseases. We are presenting five cases of abnormal chest X-rays in asymptomatic patients. First is a case of classical hilar adenopathy with parenchymal infiltrates in stage two sarcoidosis. Second case is an abnormal chest X-ray due to hair plait artifact. Third and fourth cases carry evidence of pneumoconiosis in apparently normal patient. Fifth patient had abnormal chest X-ray due to extrapulmonary cause of Morgagni hernia. Although chest X-ray plays an important role in diagnosis of various diseases, proper history taking and clinical examination are mandatory before landing up in a diagnosis.

How to cite this article: Paul PJ, Kumar DS, Srinivasan R. Divulging the Pandora Box: A Case Series of Abnormal Chest X-ray in Asymptomatic Patients. Indian J Respir Care 2023;12(4):362–365.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patients for publication of the case report details and related images.

Keywords: Asbestosis, Asymptomatic patients, Case report, Chest X-ray, Pneumoconiosis, Sarcoidosis, Silicosis, X-ray artifact

BACKGROUND

Chest X-ray was discovered by Wilhelm Röntgen in 1895, and it is an easily available imaging tool for pulmonologists and intensivists as a first-line investigation to diagnose chest diseases in symptomatic patients as well as preoperative evaluation with minimum radiation risk of 0.02 mSv.

Sometimes, abnormal shadows can be picked up in asymptomatic people. These incidental findings may be evidence of previous insult or asymptomatic ongoing pathology. Asking for proper history will avoid unnecessary computed tomography (CT) imaging and invasive biopsy procedures. Here, we are presenting an interesting case series of five cases of abnormal chest skiagram in a completely asymptomatic patient with diverse clinical backgrounds due to different etiology like pulmonary cause, artifacts, and gastrointestinal cause. Abnormal chest skiagram can also occur due to artifacts, and it can be rectified by repeat imaging, and extraintestinal cause can be easily picked up if they have gastrointestinal symptoms. Asymptomatic pulmonary sarcoidosis needs no treatment and has to be observed carefully. Pneumoconiosis can mimic infectious diseases, and occupational history is very important in pulmonology because it has a long latency period. Hence, eliciting appropriate clinical history along with radiographic abnormalities is important to arrive at proper diagnosis.

CASES DESCRIPTION

Case 1

A 45-year-old male from a rural background came for job fitness. His chest skiagram showed bilateral classical hilar adenopathy (Fig. 1). He worked in a stationary shop for >10 years, and he was never a smoker. He had no peripheral lymphadenopathy, and both testes were normal. Since patient had no complaints, he was not willing for contrast-enhanced computed tomography (CECT) chest. After heavy requests, he agreed for Mantoux test and serum angiotensin-converting enzyme (ACE) level test. His Mantoux test was nonreactive, and he had raised serum ACE levels (five times elevated). His induced sputum study was negative for tuberculosis. His electrocardiogram and ultrasonogram of abdomen were normal. His spirometry showed a normal pattern, and he was advised to come for regular follow-up. Hence, it was concluded as a case of stage two sarcoidosis with >50% chance of spontaneous resolution without treatment, and the patient is under our regular follow-up.

Fig. 1: Potato nodes—bilateral symmetrical hilar nodes with clear space between hilar nodes and heart along with right lower zone infiltrates

Case 2

A 28-year-old young female came to our outpatient department for tuberculosis screening before starting tuberculosis preventive therapy as her father was diagnosed with pulmonary tuberculosis. She has no respiratory complaints, and her clinical examination was normal. She had no addictive habits. Her screening chest skiagram (Fig. 2) had abnormal tubular-like patchy infiltrates in the left upper and mid zone. On careful examination and asking her how chest X-ray film was taken, she revealed that her hair plait was included in the chest imaging field. We repeated her chest X-ray after tying her hair plait in her head, and new chest X-ray was normal. Hence, artifacts due to hair plait may present as radiological lesions, and proper history will prevent unnecessary further investigations.

Fig. 2: Tubular-shaped patchy infiltrates in the left upper zone due to hair plait artifact

Case 3

A 43-year-old male, a milkman by occupation from rural India, came for surgical fitness. His chest X-ray film revealed bilateral diffuse miliary nodular opacities (Fig. 3). He had no respiratory issues, and he denied prior antituberculosis treatment (ATT). On repeated probing, he said that he worked in quarry for 3 years duration along with his father 15 years ago. Since his father died because of some respiratory issues, he left the quarry job and started a milk business. His spirometry showed a normal pattern, and sputum studies were negative for tuberculosis. Hence, it is a case of silicosis due to occupational exposure, and the patient may be asymptomatic at present, carrying the old evidence of silica exposure.

Fig. 3: Bilateral miliary nodular shadows

Case 4

A 63-year-old elderly male, car mechanic by profession, presented to our outpatient department for surgical fitness. He had no respiratory complaints, and his chest skiagram (Fig. 4) showed a right lower zone irregular area of hyperlucent calcific density suggestive of pleural plaques. He denied prior ATT and was never a smoker. Patient revealed a past history of shipyard construction for 5 years, 30 years ago, and left the job due to personal reasons. His spirometry showed a mild obstructive pattern with no reversibility. This is an interesting case of pleural plaques due to asbestosis.

Fig. 4: Chest X-ray showing right lower zone pleural plaques

Case 5

A 50-year-old elderly female came from a master health checkup to our outpatient department with an abnormal chest skiagram with right lower zone heterogeneous opacities with ring shadows with right diaphragm contour silhouetted (Fig. 5). Surprisingly, patient had no respiratory complaints. On auscultation, bowel sounds were heard in chest, and CT chest was taken, which showed intestinal loops and mesentery in right thoracic cavity suggestive of Morgagni hernia (Fig. 6). Patient had no other congenital anomalies. This is asymptomatic late presentation of Morgagni hernia. We advised the patient for surgical correction due to anticipated future complications of bowel strangulation.

Fig. 5: Chest X-ray—right lower zone heterogeneous opacities with silhouetting of right diaphragmatic contour

Fig. 6: CT chest—intestinal loops in the right thoracic cavity

DISCUSSION

Chest X-ray is an important first-line investigation to diagnose chest diseases based on altered radiographic opacities along with appropriate clinical and radiological correlation. Certain radiological patterns are hallmarks of certain diseases that simplify diagnosing disease. Most of the radiological patterns have a variety of differential diagnosis and needs proper history taking, including occupational history and a good clinical examination, to arrive good diagnosis.

Our first case has classical bilateral large hilar adenopathy along with right lower lobe infiltrates suggestive of stage two sarcoidosis. Sarcoidosis is a systemic granulomatous inflammatory disorder of unknown etiology. Clinically, patient is asymptomatic with a normal pulmonary function test. Patient has a high chance of spontaneous resolution.1 Only persistent and progressive pulmonary sarcoidosis needs treatment, and corticosteroids are the drug of choice.2 This patient needs continuous observation and follow-ups.

Our second case is a young female with hair plait artifact mimicking a pulmonary lesion. Always looks for artifacts like hair plait, stones in the dress, and foreign body in the dress. Otherwise, it will lead to unnecessary further investigation and further panic in patient. Calcified nipple shadow may mimic a solitary pulmonary nodule.3 In case of suspicion, omit all artifacts causing substances in radiological field and repeat chest X-ray.

Our third case has beautiful bilateral miliary shadows, which have solid evidence of previous exposure to silicosis. The characteristic features of occupational lung disorders are long latency of disease to develop in chest X-ray, and most of the time, patient ignores the past history. Hence, always probe the past history and detailed previous occupation, and differential diagnosis for miliary shadows are tuberculosis, bacterial pneumonia, viral, nontuberculous mycobacteria (NTM), silicosis, pneumoconiosis, lung adenocarcinoma, metastasis, pulmonary alveolar microlithiasis, and tropical pulmonary eosinophilia.4 Silicosis, the oldest occupational lung disorder due to the inhalation of silica dioxide, has employee compensation, and its complications are tuberculosis, NTM, obstructive airway disorders, lung cancer, scleroderma, rheumatoid arthritis, pneumothorax, and respiratory failure.5

Our fourth case has pleural plaques due to asbestosis exposure due to past occupational history of working in shipbuilding. Asbestos plaques are hyalinized collagen fibrous tissue due to asbestos fibers, and they have long latency to develop and a mean duration of 33 years.6 They reflect previous exposure to asbestosis and pleural plaques per se have no malignancy risk. They are usually bilateral and common in the lower lobe and near the mediastinal pleura. Radiology reveals holly leaf sign because of its irregular opacities, and differential diagnoses are old trauma, old hemothorax, and healed tuberculosis. Spirometry has different patterns in asbestosis.7 Other manifestations of asbestosis are benign pleural effusion, diffuse pleural thickening, mesothelioma, and lung cancer. Asbestosis also has factory compensation for employees.

Our last case is an extrapulmonary cause of abnormal lung shadows due to Morgagni hernia. Morgagni hernia is rare among congenital diaphragmatic hernia due to its right-sided anteromedial diaphragmatic defect. It is usually present in later adulthood because of its asymptomatic nature and is usually detected by incidental findings.8 Usual contents of Morgagni hernia are intestine and liver. On chest auscultation, one can hear bowel sounds that are asynchronous with respiratory sounds. Surgery needs to be addressed because of future anticipated bowel complications like strangulation, volvulus, and bowel ischemia. Recurrence rate after surgery is rare.

CONCLUSION

Physicians should be aware that abnormal chest skiagrams in asymptomatic individuals can occur, and each pattern of abnormal lung shadows has a variety of differential diagnoses. Hence, good clinic-radiological correlation is always mandatory to arrive at a correct diagnosis, and it can avoid unnecessary further interventions. Abnormal chest X-ray skiagrams can also occur due to artifacts and extrapulmonary causes. Occupational history is important in pulmonology, and pneumoconiosis can mimic other infectious diseases. Without knowledge of clinical background, interpreting chest radiology will be vain.

ORCID

Jerin Paul P https://orcid.org/0009-0007-3247-914X

Suresh Kumar D https://orcid.org/0000-0001-7528-7788

REFERENCES

1. Judson MA, Boan AD, Lackland DT. The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States. Sarcoidosis Vasc Diffuse Lung Dis 2012;29(2):119–127. PMID: 23461074

2. Baughman RP, Culver DA, Judson MA. A concise review of pulmonary sarcoidosis. Am J Respir Crit Care Med 2011;183(5):573–581. DOI: 10.1164/rccm.201006-0865CI

3. McNulty W, Cox G, Au-Yong I. Investigating the solitary pulmonary nodule. BMJ 2012;344:e2759. DOI: 10.1136/bmj.e2759

4. Rees D, Silica MJ. Parkes’ Occupational Lung Disorders, 4th edition. Boca Raton: CRC Press; 2016. pp. 187–205.

5. Lanzafame M, Vento S. Mini-review: silico-tuberculosis. J Clin Tuberc Other Mycobact Dis 2021;23:100218. DOI: 10.1016/j.jctube.2021.100218

6. Norbet C, Joseph A, Rossi SS, et al. Asbestos-related lung disease: a pictorial review. Curr Probl Diagn Radiol 2015;44(4):371–382. DOI: 10.1067/j.cpradiol.2014.10.002

7. Abejie BA, Wang X, Kales SN, et al. Patterns of pulmonary dysfunction in asbestos workers: a cross-sectional study. J Occup Med Toxicol 2010;5:12. DOI: 10.1186/1745-6673-5-12

8. Kuikel S, Shrestha S, Thapa S, et al. Morgagni hernia in adult: a case report. Int J Surg Case Rep 2021;85:106286. DOI: 10.1016/j.ijscr.2021.106286

________________________
© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.