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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 53

Localized hyper translucency


Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India

Date of Submission13-May-2021
Date of Acceptance19-Jul-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Vishnu Sharma
Department of Respiratory Medicine, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_24_21

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How to cite this article:
Sharma V, Shekar NC. Localized hyper translucency. J Assoc Pulmonologist Tamilnadu 2021;4:53

How to cite this URL:
Sharma V, Shekar NC. Localized hyper translucency. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 Jan 28];4:53. Available from: http://www.japt.com/text.asp?2021/4/1/53/326410




  Question Top


This was the chest X-ray of a patient admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD). What is the abnormality in the chest X-ray? [Figure 1]
Figure 1: Chest x Ray

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  Answer Top


Bilateral skinfold artifact (mimicking pneumothorax). Features of emphysema - Hyperinflation of lungs, hyper translucency in the lower lung fields, reduced bronchovascular markings, depressed low down flattened diaphragm, and blunting of the costophrenic angles are also evident. Callus is seen in both clavicles indicating old healed fracture.

One of the causes for acute exacerbation dyspnea in COPD is pneumothorax. Encysted pneumothorax should be radiologically differentiated from Bulla, skinfold artifact, large cyst, large cavity, and overlying soft tissue margin.[1]

Skinfold artifact is more common in anteroposterior chest radiograph. It is due to the redundant skin fold. This is more common in patients who are elderly, debilitated, and recent weight loss where the skin is usually loose.[2] Such patients when they lay on the X-ray plate, skin folding occur usually at the lower hemithorax.

Skinfold artifact should be differentiated from encysted pneumothorax as pneumothorax in a breathless patient requires immediate intercostal tube drain. Pneumothorax is characterized by peripheral hyper translucent area devoid of bronchovascular markings, bounded medially by the sharp well-defined visceral pleural line.[1] This visceral pleural line follows the boundaries of the thoracic cage. Margins of the skinfold artifact are usually ill defined, broad compared to visceral pleural line, can be traced beyond the thoracic cage.[3] The hyper translucent area will show bronchovascular markings. In pneumothorax, peripheral convex edge of collapsed lung and mediastinal shift may be evident.

When doubt exists bedside thoracic ultrasound can help to differentiate between the two conditions. Ultrasonographic signs of pneumothorax include the absence of lung sliding, absence of B-lines, absence of comet tail artifacts, presence of A-lines, and presence of the lung point sign.[4] Ultrasound being portable has the advantage in critically ill patients. Some patients may require computed tomography for definitive diagnosis. This is more so in patients with COPD who can have bulla with pneumothorax and patients with underlying parenchymal lung disease where sonography may be suboptimal to visualize the parenchymal lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nirmal AS, Vishnu Sharma M, Alphonse AJ, Adarsh N, Harshith N. Interactive case discussion – Hyper translucent hemithorax. Int J Curr Res 2020;12:10747-9.  Back to cited text no. 1
    
2.
Kattea MO, Lababede O. Differentiating pneumothorax from the common radiographic skinfold artifact. Ann Am Thorac Soc 2015;12:928-31.  Back to cited text no. 2
    
3.
Fisher JK. Skin fold versus pneumothorax. AJR Am J Roentgenol 1978;130:791-2.  Back to cited text no. 3
    
4.
Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 2012;5:76-81.  Back to cited text no. 4
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