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| IMAGE QUIZ |
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| Year : 2013 | Volume
: 1
| Issue : 2 | Page : 119 |
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Dyspnea in an elderly male
Abdelhaleem Bella, Kawthar Hadhiah
Department of Internal Medicine, King Fahad Hospital of the University, College of Medicine, University of Dammam, Saudi Arabia
| Date of Web Publication | 25-Dec-2013 |
Correspondence Address:
Abdelhaleem Bella
P.O. Box 76104, Al-Khobar 31952
Saudi Arabia
 DOI: 10.4103/1658-631X.123651 
How to cite this article:
Bella A, Hadhiah K. Dyspnea in an elderly male. Saudi J Med Med Sci 2013;1:119 |
A 58-year-old Saudi male patient presented with a progressive exertional shortness of breath associated with cough productive of mucoid sputum and had no fever or hemoptysis. And also he had a history of chronic cough and recurrent chest infection which was labeled as asthma and treated with inhaled bronchodilators. He didn't smoke and had no family history of similar condition or asthma. Patient was a febrile, his respiratory rate was 26 breathes per min. He had clubbing. His blood pressure was 115/70 mmHg, oxygen saturation was 85% in room air. His chest examination showed expiratory rhonchi and bilateral coarse crepitations more in the left base. There was mild pitting lower limbs edema. His pulmonary function test showed irreversible obstructive pattern with a forced expiratory volume in one second (FEV1) of 0.75 L/min (40% predicted). His echocardiogram showed pulmonary artery pressure of 35 mmHg. His chest radiograph [Figure 1] and a contrast enhanced computed tomography (CT) chest [Figure 2] are shown below. | Figure 1: Hyperlucent left lung with pulmonary artery enlargement on the right side
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 | Figure 2: Computed tomography chest shows bronchiectasis, hypoperfusion and diminished vascularity on the left side
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| Questions | |  |
What is the diagnosis?
How would this patient be managed?
| Answers | | |
The chest X-ray [Figure 1] shows hyperlucency of the left lung with an enlargement of the pulmonary vessels on the right side. The CT chest [Figure 2] shows: bronchiectasis, diminished vascularity/hypoperfusion and hyperinflation on the left lung consistent with a diagnosis of Swyer-James-Macleod syndrome (SJMS). [1],[2] It is an acquired disease, post-infectious bronchiolitis in childhood, including viral and bacterial bronchiolitis. The affected patient may be asymptomatic, or may present with an airway disease suggestive of asthma and bronchiectasis. The investigations required includes CT pulmonary angiography and high resolution computed tomography, pulmonary function tests, ventilation perfusion scan and echocardiography. The differential diagnosis includes many causes of unilateral hyperlucency (shown below), it may be confused with pneumothorax and so chest drain may be wrongly inserted. [3] Almost all the reported cases of SJMS were managed medically through bronchodilators, prevention and treatment of recurrent pulmonary infections and few had surgery. [4]
| References | | |
| 1. | Swyer PR, James GC. A case of unilateral pulmonary emphysema. Thorax 1953;8:133-6. 
[PUBMED] |
| 2. | Macleod WM. Abnormal transradiancy of one lung. Thorax 1954;9:147-53.
[PUBMED] |
| 3. | Metin B, Özkan E, Sariçam M, Ariba OK. Swyer-James-MacLeod syndrome with renal ectopy misdiagnosed as pneumothorax and chest tube drained: Case study. J Thorac Cardiovasc Surg 2013;145:e44-7.
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| 4. | Vishnevsky AA, Nikoladze GD. New approach to the surgical treatment of Swyer-James-MacLeod syndrome. Ann Thorac Surg 1990;50:103-4.
[PUBMED] |
[Figure 1], [Figure 2]
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