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Communications to the Editor |

Reversible Unilateral Diaphragmatic Paralysis in Pulmonary Embolism FREE TO VIEW

Katharina Pils, MD; Raimund Märk, MD; Peter Pils, MD
Author and Funding Information

Sophienspital, Vienna, Austria Rehabilitation Center Weisser Hof Klosterneuburg, Austria Department of Occupational Diseases, Tobelbad, Austria

Correspondence to: Peter Pils, MD, Department of Occupational Diseases, A-8144 Tobelbad, Austria



Chest. 1999;116(2):587-588. doi:10.1378/chest.116.2.587-b
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To the Editor:

We observed a 28-year-old previously healthy male patient who was admitted to the Spinal Cord Injury Rehabilitation Center with fracture of the 12th corpus vertebrae and subsequent complete paraplegia 1 month after a road accident. The chest radiograph on admission was normal. Two months later, a few days after anticoagulant therapy cessation for ongoing mobilization, the patient developed sudden right-sided chest pain, tachypnea, and worsening of the clinical presentation. The chest radiograph showed an elevated right hemidiaphragm, which was highly suggestive of an acute pulmonary embolism (PE). Other investigations, such as angiography or radionuclide imaging, were not available. On a video-assisted fluoroscopy, with the urologic examination equipment tilted in a 30° position, a poor mobility of the right hemidiaphragm was demonstrated, and the sniff maneuver showed a paradoxical movement (we were used to using this diagnostic tool in order to rule out posttraumatic phrenic nerve paresis). One month later, the patient still complained of a right-sided chest pain, and the fluoroscopy showed a pleural-based ill-defined opacity, a poorly moving right hemidiaphragm, and an ambiguous answer to the sniff maneuver. Two months later, while supported by a routine management with anticoagulants, antibiotics, and analgesics, the patient felt well, the chest radiograph returned to normal, and the answer to the sniff maneuver showed no impairment of the diaphragmatic mobility.

Palevsky et al1state that “one hemidiaphragm is occasionally elevated, presumably as a consequence of ipsilateral reduction in lung volume.” More than 30 years ago, the Encyclopedia of Medical Radiology2mentioned the elevated hemidiaphragm as a common symptom of PE and suggested that it was a neural reflex mechanism with a subsequent “transient paralysis of the diaphragm.” But some 20 years later, the same encyclopedia only stated the fact that the elevated hemidiaphragm is an important diagnostic sign without further explanation. Reflex and humoral responses to PE were described, but the encyclopedia did not refer to an impairment of diaphragma function.3

We demonstrated the transient palsy of the hemidiaphragm by fluoroscopy and sniff maneuver in acute PE. From a teleologic point of view, this phenomenon may correspond to a “plaster cast” of the affected lung; however, it induces poor ventilation and therefore, a higher risk of pneumonia, which should lead to an early administration of potent antibiotics.

Clarification

In the June 1999 issue, the article “Assessment of Hazardous Dust Exposure by BAL and Induced Sputum” (CHEST 1999;115:1720–1728) by Fireman et al did not include the source of funding. This work was supported by the Committee for Research and Prevention in Occupational Safety and Health, Ministry of Labor and Social Affairs, Israel.

References

Palevsky, HI, Kelley, MA, Fishman, AP (1998) Pulmonary thromboembolic disease. Fishman, AP Elias, TA Fishman, TAet al eds.Fishman′s pulmonary diseases and disorders,1309 McGraw-Hill. New York, NY:
 
Sielaff, HJ Pulmonary embolism. Diethelm, L Olson, O Strnad, Fet al eds.Encyclopedia of medical radiology (vol 9)1968,609-616 Springer Verlag. New York, NY:
 
Stein, M, Lewy, SE Reflex and humoral responses to pulmonary embolism.Prog Cardiovasc Dis1974;17,167-174. [CrossRef]
 

Figures

Tables

References

Palevsky, HI, Kelley, MA, Fishman, AP (1998) Pulmonary thromboembolic disease. Fishman, AP Elias, TA Fishman, TAet al eds.Fishman′s pulmonary diseases and disorders,1309 McGraw-Hill. New York, NY:
 
Sielaff, HJ Pulmonary embolism. Diethelm, L Olson, O Strnad, Fet al eds.Encyclopedia of medical radiology (vol 9)1968,609-616 Springer Verlag. New York, NY:
 
Stein, M, Lewy, SE Reflex and humoral responses to pulmonary embolism.Prog Cardiovasc Dis1974;17,167-174. [CrossRef]
 
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