A case of luftsichel sign for left upper lobe collapse.

The differential diagnosis of dyspnea in Emergency Department (ED) patients is broad and atelectasis is one of the differentials among these. We present a 29-year-old women presented to our ED for evaluation of shortness of breath. On her chest examination, air entry and breath sounds were diminished on the left side but normal on the right. A posteroanterior chest radiograph showed radioluscent area in the upper zone of the left lung, around the aortic arch and also hyperdens area neighbouring this, like covered by a veil. Luftsichel sign together with this hiperdensity were consistent with the diagnose of left lung upper lobe collapse. The Luftsichel sign represents the hyperexpanded superior segment of the left lower lobe interposed between the atelectatic left upper lobe and aortic arch. Patient was discharged to home with chest physiotherapy and breathing exercises together with analgesic prescreption.

INTRODUCTION

The differential diagnosis of dyspnea in emergency department (ED) patients is broad and atelectasis is one of the differentials among these. Timely recognition of lung collapse is critical and may influence a clinician's acute management. We present the case of a dyspneic patient with the presence of luftsichel's sign, which has been regarded as a very rare radiologic finding in chest radiography and represents the left lung upper lobe collapse (LLULC).[1]

CASE REPORT

A 29-year-old woman presented to our ED for evaluation of shortness of breath. Her dyspnea began 3 days ago after cesarean delivery of her baby. She complained of difficulty in coughing for these 3 days but denied fever, chills, hemoptysis, weight loss, night sweats and calf pain. Her past medical history was unremarkable except cesarean section. She had worked as a housewife but denied any exposure to animals. On examination, the patient was not in respiratory distress clinically. Vital signs were as follows: Temperature 37.4°C; heart rate 86 beats/min; respiratory rate 27 breaths/min; and arterial oxygen saturation 90% while breathing in room air. On chest examination, air entry and breath sounds were diminished on the left side but normal on the right. Cardiovascular examination showed regular rhythm. The abdominal examination was normal except a scar of Pfannenstiel incision and extremities were warm without edema.

Complete blood count showed normal levels of blood cells. Her biochemistry panels were in normal limits except increased creatine kinase level 178 U/L (29-168 U/L). The coagulation profile was normal, and the patient's D-dimer (quantitative) level was minimally elevated at 462 ng/ml (<243 ng/ml).

A posteroanterior chest radiograph [Figure 1] showed radiolucent area in the upper zone of the left lung, around the aortic arch and also hyperdense area neighboring this, like covered by a veil. Luftsichel sign together with this hyperdensity were consistent with the diagnose of LLULC. With the aid of history, physical examination, and chest radiograph, the patient was diagnosed as LLULC due to mucous plague obstruction because of inadequate coughing. Patient was discharged to home with chest physiotherapy and breathing exercises together with analgesic prescription. After 2 weeks of discharge, the patient was found to be healthy without any complaint.

Figure 1

(a) Chest radiogram of the patient (b) luftsichel sign is marked with dotted line on the chest radiogram of the patient

DISCUSSION

Chest radiography is the first ordered radiodiagnostic test in the evaluation of emergent patients with dyspnea due to low cost and radiation dose. Collapse of the lung may present in varied combinations of signs in chest radiography. The direct signs include displacement of fissures, loss of aeration and crowding of vessels. Indirect signs such as tracheal shift, mediastinal shift, rib crowding, compensatory inflation of the remaining lung and hilar displacement may also be visualized in chest radiograph.[2] The luftsichel (German word for air-sickle) sign represents the hyperexpanded superior segment of the left lower lobe interposed between the atelectatic left upper lobe and aortic arch. As the LLULC, it moves anteriorly to lie against the anterior chest wall, with the hyperexpanded left lower lobe located behind the upper lobe.[3]