Images in Clinical Medicine

An Unusual Case of Orthopnea

Probal K. Moulik, M.R.C.P, and Justine Hadcroft, M.R.C.P.

N Engl J Med 2002; 347:193July 18, 2002

• Slide

Article

Figure 1 A 62-year-old former smoker presented with a 20-year history of breathlessness that worsened when she lay flat and particularly when she swam. Chest radiography (Panel A) showed an elevated left hemidiaphragm and a mediastinal shift to the right. Fluoroscopy revealed a paradoxical movement of the left hemidiaphragm. Spirometry demonstrated a forced vital capacity of 1.28 liters when the patient was supine that increased to 1.44 liters when she stood. Magnetic resonance imaging of the chest (Panel B) revealed a defect in the left hemidiaphragm (black arrows), with herniation of the stomach and colon (white arrow) into the chest. Congenital diaphragmatic hernias are usually detected in infancy and are an uncommon cause of breathlessness in adults. Increased breathlessness on lying flat or swimming is a classic symptom of diaphragmatic weakness or hernia. Treatment is surgical — usually open repair — although attempts are being made to develop thoracoscopic techniques. This patient, however, declined surgery.

Probal K. Moulik, M.R.C.P
Justine Hadcroft, M.R.C.P.
University Hospital Aintree, Liverpool L9 7AL, United Kingdom