Dyspnea and Mild Intermittent Cough in a Nonagenarian: Page 2 of 2
Answer: Pseudotumors (C)
The clinical diagnosis of pseudotumors in this patient is based on the radiographic findings of fluid in the fissures (Figure 1). The diagnosis was confirmed by a computed tomography scan, which showed three homogenous densities of -10 Hounsfield units (HU) to -20 HU abutting the fissures, consistent with pseudotumors. The patient was hospitalized and treated with intravenous furosemide. Her dyspnea improved and a chest radiograph taken on hospital day 5 showed the masses had disappeared (Figure 2).
Pseudotumors are sharply marginated collections of pleural fluid contained within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure.1 They result from transudation from the pulmonary vascular space and have a biconvex contour. More than 75% occur in minor (horizontal) fissures and are seen on both the frontal and lateral radiographs; however, those that occur in major (oblique) fissures may only be readily visible on the lateral view.1 In rare cases, pseudotumors occur in minor and major fissures simultaneously. The case patient’s pseudotumors measured approximately 6 cm each, but most lesions have been reported to be <4 cm.1
Pseudotumors are often incidental radiographic findings in patients with congestive heart failure. Interlobar pleural effusions do not correspond to left heart failure severity and may be the only sign of cardiac decompensation.1 The differential diagnosis of loculated pleural effusions in fissures includes transudates from left ventricular failure or renal failure, exudates, hemothorax, chylothorax, malignant pleural effusions, and fibrous tumors originating from the visceral pleura of the interlobar fissure. If a pseudotumor is correctly diagnosed, it will have little impact on patient management; however, pseudotumors may be easily misdiagnosed as lung masses. When a misdiagnosis occurs, it can lead to expensive imaging studies, invasive procedures (eg, biopsies), unwarranted use of antibiotics, and needless patient and family anxiety.
Although pseudotumor is an uncommon presentation of congestive heart failure, it may be seen more frequently in geriatric patients and in residents of long-term care facilities because there is a high incidence of congestive heart failure in this population.
Dr. Bernacki is director of quality initiatives, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.
The author reports no relevant financial relationships.
1.Haus BM, Stark P, Shofer SL, Kuschner WG. Massive pulmonary pseudotumor. Chest. 2003;124(2):758-760. www.learningradiology.com/archives05/COW%20159-Pseudotumor/pseudotumorco.... Accessed October 19, 2011.