31. Here in this new case we have similar findings (left hemithorax is markedly reduced in size). But the underlying disease is completely different; unchanged for months. A long history with long lasting pleurisy.
We are back in the pleura: pleural scars can calcify;
extensive pleural scarring = fibrothorax. Of course fibrothorax can calcify. The rules for a post-inflammatory pleura calcification are not clear. The extent of the calcification does not strongly correlate with the degree of restriction! Detection of calcification does not help to clarify the ethiology (bacterial empyema, specific pleurisy, hemothorax?).
Bild 31
- Why is the proof of pleural calcification important?
(Click here for the answer) Calcification is very helpful to localise the disease as a pleural disease. It helps to recognize the complications. (This will be demonstrated later in several cases).
Once again: what is the impact of pleural scars? (anatomic view) It is primarily a restrictive impact.
The shrinking of the lung causes:
Restriction of breathing movement,
Reduction of lung volume,
Distortion of the mediastinum,
Distortion of the diaphragm,
Scoliosis,
Thickening of the thoracic ribs (Eyler),
Narrowing intercostal spaces.
Fibrothorax can, as in this case, reach excessive proportions. In plethysmography we find strong restrictive changes.
How does the restrictive impact take shape in this present case?
(Click here for the answer)
Mediastinum strongly warped towards the right; particularly evident in the trachea. Severe reduction of the right thoracic cavity, significant scoliosis, the right ribs are forced into an expiration position, clear thickening of the ribs (compared with the opposite side)!
32. Note the typical uncalcified layer (mostly fat) between calcification and ribs. This layer ensures a degree of mobility of the remaining right lung. Such fatty tissues can arise in various shrinking processes. Restrictive changes are strong and often underestimated. The enthrallment of the lung by pleura causes 8 radiological signs which are all quite similar to the anatomical results mentioned above in the last case.
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- To reiterate... as mentioned previously:
(Click here for the answer) Uncalcified epipleural layer,
Thickening of ribs,
Reduction of the thoracic cavity,
Expiration position of the ribs,
Thickening of the ribs (in comparison to opposite side),
Narrowed intercostal space,
Scoliosis,
Mediastinal distortion (here less developed).
If you did not detect so many signs or indications, you should use the next 8 images as room for improvement, otherwise move on to case number 41.
33. Repeat the 8 symptoms of this right-sited fibrothorax in this film.
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- Which of these are more or less pronounced? What could an additional finding be?
(Click here for the answer) Particularly clear:
epipleural fat layer,
elevation of the diaphragm,
tracheal shift, the heart remains in its place,
no statement about rib pathology.
A splinter is more likely to show the reason of fibrothorax: empyema after splinter injury.
As a new additional finding: acute pleural effusion to the left; after a minor puncture one finds a mirror = Seropneumothorax.
Again, on the right side a calcified fibrothorax, on the left side a fresh pleural effusion. The pleura can calcify irregularly (but also very evenly).
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- Which of the effects of the fibrothorax are less clear?
(Click here for the answer) The epipleural fat and thickening of the ribs are not clearly demonstrated. This can happen.
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- What is recognizable?
(Click here for the answer) The overview x-ray is underexposed (and low KV?) and proper diagnosis is not possible. In CT examination - here in the form of a 3D reconstruction - we can see a clearly calcified fibrothorax on both sides. A possible suggestion could be that the location is completely "untypical”. Do not assume a favourite location of pleural calcification.