History
A 9-year-old castrated male Italian Greyhound that weighed 5.6 kg (12.3 lb) was admitted to the emergency service for a 5-day history of exercise intolerance and possible difficulty breathing and a 3-day history of gagging and coughing. The dog had fallen off the bed and developed a large contusion on the right side of the ventral aspect of the thorax 2 weeks previously, which had since resolved. The dog was bright, alert, responsive, and stable at the time of admission. Respiratory sounds were decreased to undetectable in the right middle to caudal lung field region. Abnormal laboratory values included mild bilirubinemia and hematuria and bilirubinuria on urinalysis of a free-catch urine sample. Thoracic radiographs were obtained (Figure 1).
Left lateral (A) and ventrodorsal (B) radiographic views of a 9-year-old castrated male Italian Greyhound evaluated because of a 5-day history of exercise intolerance with possible difficulty breathing and 3-day history of gagging and coughing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Left lateral (A) and ventrodorsal (B) radiographic views of a 9-year-old castrated male Italian Greyhound evaluated because of a 5-day history of exercise intolerance with possible difficulty breathing and 3-day history of gagging and coughing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Left lateral (A) and ventrodorsal (B) radiographic views of a 9-year-old castrated male Italian Greyhound evaluated because of a 5-day history of exercise intolerance with possible difficulty breathing and 3-day history of gagging and coughing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Determine whether additional imaging studies are required, or make your diagnosis from Figure 1—then turn the page →
Radiographic Findings and Interpretation
A large (5.0 × 6.4-cm) mass is identified in the caudal aspect of the right hemithorax on the ventrodorsal and left lateral radiographic views. The periphery of the mass appears as a thin-walled soft tissue opacity, and the opacity of the central portion of the mass is less than expected for a solid or fluid-filled mass of this size. A distinct horizontal fluid-air interface is evident within the mass on a lateral radiographic view of the thorax that was obtained while the dog was in a standing position (Figure 2). The additional radiographic view was obtained to document the presence of fluid and air within the mass. Radiographic changes are consistent with a traumatic pulmonary hematocele. A small, round soft tissue nodule is also seen in the ventral aspect of the right middle lung lobe and may represent a similar fluid-filled structure. Ultrasound-guided aspiration of the larger lesion confirmed the hemorrhagic content, verifying the radiographic diagnosis of hematocele.
Same left lateral radiographic view as Figure 1 (A) taken while the dog was recumbent, and a left lateral (B) radiographic view of the thorax of the same dog taken while in a standing position. A large mass (arrow) of the right caudal lung lobe is visible on the left lateral radiographic view obtained during recumbency; a smaller soft tissue nodule (arrowhead) is evident in the periphery of the right middle lung lobe (fourth intercostal space superimposed over the ventral aspect of the cardiac silhouette). A horizontal fluid-air interface is detected in the large mass of the right caudal lobe on the left lateral thoracic image obtained in the standing position by use of horizontal beam radiography. The thin wall (asterisk) suggested on the left lateral radiographic view obtained during recumbency is verified on the dorsal aspect of the mass on the lateral radiographic view taken while standing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Same left lateral radiographic view as Figure 1 (A) taken while the dog was recumbent, and a left lateral (B) radiographic view of the thorax of the same dog taken while in a standing position. A large mass (arrow) of the right caudal lung lobe is visible on the left lateral radiographic view obtained during recumbency; a smaller soft tissue nodule (arrowhead) is evident in the periphery of the right middle lung lobe (fourth intercostal space superimposed over the ventral aspect of the cardiac silhouette). A horizontal fluid-air interface is detected in the large mass of the right caudal lobe on the left lateral thoracic image obtained in the standing position by use of horizontal beam radiography. The thin wall (asterisk) suggested on the left lateral radiographic view obtained during recumbency is verified on the dorsal aspect of the mass on the lateral radiographic view taken while standing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Same left lateral radiographic view as Figure 1 (A) taken while the dog was recumbent, and a left lateral (B) radiographic view of the thorax of the same dog taken while in a standing position. A large mass (arrow) of the right caudal lung lobe is visible on the left lateral radiographic view obtained during recumbency; a smaller soft tissue nodule (arrowhead) is evident in the periphery of the right middle lung lobe (fourth intercostal space superimposed over the ventral aspect of the cardiac silhouette). A horizontal fluid-air interface is detected in the large mass of the right caudal lobe on the left lateral thoracic image obtained in the standing position by use of horizontal beam radiography. The thin wall (asterisk) suggested on the left lateral radiographic view obtained during recumbency is verified on the dorsal aspect of the mass on the lateral radiographic view taken while standing.
Citation: Journal of the American Veterinary Medical Association 236, 5; 10.2460/javma.236.5.515
Comments
Traumatic pulmonary hematoceles, which may also be referred to as blood-filled traumatic pulmonary bulla or traumatic pulmonary pseudocysts, are uncommon causes of nodular lung disease reported in the veterinary and human medical literature.1,2 Pathogenesis of these lesions is postulated to involve blunt trauma to the thorax, which causes an intrapulmonary parenchymal laceration with intact visceral pleura, with or without associated vascular damage.3,4 The resulting lesion fills with air, growing in size until pressures equalize between the area of the destroyed tissue and the remainder of the lung.1,3 If associated vasculature is also lacerated, blood will invade the space, resulting in a cavitary lesion.1,3 In human medicine, computed tomography has largely replaced radiography as the diagnostic imaging technique of choice for pleural disease following trauma. In 1 study,3 traumatic pulmonary pseudocysts (hematoceles) were often missed on evaluation by use of thoracic radiography, particularly when images were obtained in the supine (dorsal) position (vertical beam radiography), while computed tomography allowed identification of all pseudocysts. It is hypothesized that associated injuries such as lung contusion can make it difficult to identify traumatic pulmonary hematoceles in the acute phase.1,3 Because of costs, availability, and the necessity of anesthesia, computed tomography may not be practical in veterinary medicine, and conventional radiology continues to be the mainstay for most evaluations of the thorax. Fluid-filled spaces are indistinguishable from solid tissue masses radiographically; however, a cavitary lesion containing both fluid and air that may be mistaken for a soft tissue mass on conventional radiographic views could be differentiated by use of additional positional radiographic views.5 The use of horizontal beam radiography should be considered, especially when the opacity of the structure is less than expected for a solid or fluid-filled structure of that size. If a structure has an air-fluid interface, horizontal beam radiography can allow more precise characterization of a lesion than routine radiographic views by observing the gravitational effect on the cavity's contents.1,5,6 In the dog of this report, the fluid-air interface within the otherwise thin-walled pulmonary lesion and recovery of blood via ultrasound-guided aspiration of the lesion suggested that the reported trauma resulted in formation of a bulla with subsequent bleeding into the air-filled sac, resulting in the pulmonary hematocele.
Reduction in size of the pulmonary hematocele was documented on follow-up thoracic radiographic views prior to discharge from the hospital. The patient was discharged without clinical signs of respiratory problems and was reportedly doing well 1 month later.
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