72 yo F with a “total lung white out”

Original case by Lauren Brown, MD.
Edits, updates and graphics by Yilin Zhang, MD.


OBJECTIVES:

  • List causes of a “total lung white out” or opacified hemithorax
  • Recognize how a CXR may help you differentiate between these causes

Click here for the clinical case version of this vignette (~10-15 min) that contains additional teaching points on her final diagnosis.


CASE:

A 72 yo F with recently diagnosed metastatic renal cell carcinoma presents with 1 week of increasing shortness of breath and nonproductive cough. One week ago, she was diagnosed with a LLL segmental and subsequental PE and was started on therapeutic enoxaparin. Within days of starting anticoagulation, she reports worsening shortness of breath. She otherwise denies any fevers, chills, hemoptysis.

She has renal cell carcinoma metastatic to the liver and lymph nodes for which she is taking nivolumab. On exam is she afebrile, tachycardic to 110s, RR 22, 96% on RA. She has absent breath sounds in the R hemithorax.

CXR

What is your differential for an opacified L hemithorax? 


OUTCOME:

TAKE HOME POINTS:

  • Look at the deviation of the trachea to narrow the diagnosis of an opacified hemithorax (aka “total lung white out”).