Same patient.

chronic empyema aspiration

chronic empyema aspiration

Which method should be performed in order to determine whether the persisting effusion is infected?
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It is implemented in the prone position. We see the image turned in a supine position. The direction of the needle avoids the large vessels. It reveals protein-rich fluid, the bacteriology is negative.

Take-home message:
imaging gives no answer on persisting effusions bacteriology. Despite decades of sterility, it can be suddenly infectiously activated without giving a morphological hint.

New patient 47:

51 years ago, in 1958, this case was published in "Tuberkulose Arzt”. The author, HG Schmitt, would be 102 years old. He had first seen the patient in 1944; it was then that his interest for pleural pathology commenced:

our patient is a 38-year old man who had prolonged pleurisy in 1958,  16 years prior to the admission. The overview x-ray (in low KV-technique) shows no calcification.

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case from 1949

Which (wrong) diagnosis was probably made first?
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One suspected a neoplastic mass. Your answer is right.  – The next picture shows a simple method which gives new information.

120 kV and Bucky-Potter grid demonstrate a large, homogenous, globular shadow enveloped by a calcified shell .  

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Which investigations would we request today?
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Sonography and CT. Both did not exist at that time. It would  verify a chronic, persistent effusion bordered by calcified  visceral and parietal pleura.
Note the uncalcified layer between parietal pleura and the inner thoracic wall. -
In 1953 they performed the following exam:

A conventional axial tomography.

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transversal tomography 1950

What is visible?
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Spine, aorta descendens, heart shadow and the voluminous persistent effusion, which is surrounded by a calcified layer.

Radiograph of the operative specimen, demonstrating the envelope of irregular calcified connective tissue.

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after decortication