We leave the pleura and go to an entirely different disease. But the same (mis-)diagnosis was made, as it was in the previous case: pneumonia.
The 44-year-old craftsman suffered from a respiratory infection.

Bild 66

Poland Syndrom

A. shows the PA-film: middle lobe pneumonia? B. Watch the patient and not only the x-ray; this will give you the answer.
(Click here for the answer)

In the PA film we miss the (often) typical aerobronchography. It means  high contrast through increased lung density but air containing bronchi; bronchi are cleared by coughing and appear within the dense parenchyma as black bands or black spots, depending on the projection.
This patient shows no aerobronchography but he has an aplasia of left musculus pectoralis.
So his left thorax with the smaller soft-tissue envelope appears translucent. Due to this anatomy his right thorax is slightly underexposed, simulating an opacity (not a real finding).

Back to the pleura: this 74-year-old woman had a pulmonary tuberculosis  51 years earlier and was treated for right-sited pneumothorax for 2 years. At the age of 64, she had surgery for carcinoma of the breast. Over the past 4 years she had demonstrated fever on three occasions, and mycobacterium tuberculosis was isolated from her sputum after repeated attempts.
A radiograph two months ago shows a huge pleural shadow, incorrectly diagnosed as fibrous tissue.

Bild 67

Pleural shadow

What is the calcification in the apex within the shadow?
(Click here for the answer)

This calcified line represents the outer wall of the fluid filled cavity!  
Follow up makes the diagnosis much easier.

 At that time our patient had a sudden and massive expectoration.
From the actual x-ray we are able to understand the pleural shadow - in image 67 - much better:  in its inner part it is an effusion which is now replaced by air. The empyema became pneumothorax due to a connection to the bronchial system. We don’t see this pleuro-bronchial fistula, but its existence is obvious. After this drainage via the airways:

Bild 68

Pleuro-bronchial fistula

does a part of the original shadow remain? Is this sign present in a healthy person?
(Click here for the answer)

Yes. It is the layer of fat outside the pleura parietalis, which we observe in many shrinking lesions.
Thickened visceral pleura have been nicely lined out. -

More sudden complications of persistent effusions are presented in 72-75.

Bild 69

shadow thicker than

Summarize the take-home message given in this picture.
(Click here for the answer)

A pleural shadow thicker than a finger
(about 2 cm) is most likely a residual effusion. -
Following such conditions one frequently finds complications.
An even safer sign is the presence of more than one calcified band indicating an effusion separating both pleurae.

Here is a 65-year old doctor: at the age of 30 years he had suffered from pleural empyema; the pleura is only moderately calcified. The right thoracic cavity is restricted in expiration-position; ribs are thickened. He asked: is it possible to improve my restriction?

Bild 70

chronic empyema