Clinical Cases

HomeProfessionalsClinical ResourcesClinical Cases ▶ Near-Complete Opacification of the Right Hemithorax
Near-Complete Opacification of the Right Hemithorax

Reviewed By Clinical Problems Assembly

Submitted by

Christopher B. Remakus, M.D.


Pulmonary and Critical Care Medicine

Temple University School of Medicine

Philadelphia, PA

Victor Kim, M.D.

Assistant Professor of Medicine

Pulmonary and Critical Care Medicine

Temple University School of Medicine

Philadelphia, PA

Submit your comments to the author(s).


A 78-year-old African-American man presents to the emergency room complaining of malaise for one week. He denies shortness of breath, dyspnea on exertion, chest pain, fever or night sweats. On further questioning, however, he acknowledges a productive cough, nausea, vomiting, anorexia, a 10-pound weight loss and generalized weakness. The remainder of the review of systems is negative. He has no significant past medical history. He takes no medications. His family history is noncontributory. He denies tobacco, alcohol or illicit drug use. He is visiting Philadelphia, Pennsylvania from his home in Charleston, South Carolina, but his travel history is otherwise unremarkable.

Physical Exam

His temperature is 102.9°F, heart rate is 88 beats per minute, respiratory rate is 16 breaths per minute, blood pressure is 127/77 mm Hg and pulse oximetry is 92% on room air. On examination, he is cachetic but in no acute distress. His trachea is midline and he has no jugular venous distension. His heart sounds are regular with a normal S1 and S2 and no murmurs, rubs or gallops. His lung exam reveals markedly decreased breath sounds in the right hemithorax. His abdomen is soft, nontender and nondistended ,and there is no hepatosplenomegaly. He has no lower extremity edema. There are no neurological deficits. The remainder of his physical examination is unremarkable.


His white blood cell count is 10.4 x 109/L with 78% segmented neutrophils. He is mildly anemic (hemoglobin 11.0 g/dl) and his platelet count is within normal limits (252 x 109/L). His basic metabolic panel is unremarkable. A posteroanterior and lateral chest radiograph is shown below (see Figure 1).


Figure 1. PA chest radiograph showing near-complete opacification of the right hemithorax with an air-fluid level at the right apex.

Question 1

What is the most likely diagnosis?


  1. Reynolds JC, Parkman HP. Achalasia. Gastroenterol Clin North Am 1989;18:223-255.
  2. Hughes RL, Freilich RA, Bytell DE, Craig RM, Moran JM. Clinical conference in pulmonary disease. Aspiration and occult esophageal disorders. Chest 1981;80:489-495.
  3. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med 1987;82:439-446.
  4. Vaezi MF, Richter JE. Diagnosis and management of achalasia. Am J Gastroenterol 1999;94:3406-3412.
  5. Hadjiliadis D, Adlakha A, Prakash U. Rapidly growing mycobacterial lung infection in association with esophageal disorders. Mayo Clin Proc 1999;74:45-51.
  6. Cuilliere C, Ducrotte P, Zerbib F, Metman EH, de Looze D, Guillemot F, Hudziak H, Lamouliatte H, Grimaud JC, Ropert A, Dapoigny M, Bost R, Lemann M, Bigard MA, Denis P, Auget JL, Galmiche JP, Bruley des Varannes S. Achalasia: Outcome of patients treated with intrasphincteric injection of botulinum toxin. Gut 1997;41:87-92.
  7. Levine ML, Moskowitz GW, Dorf BS, Bank S. Pneumatic dilation in patients with achalasia with a modified Gruntzig dilator (Levine) under direct endoscopic control: Results after 5 years. Am J Gastroenterol 1991;86:1581-1584.
  8. Kadakia SC, Wong RK. Graded pneumatic dilation using Rigiflex achalasia dilators in patients with primary esophageal achalasia. Am J Gastroenterol 1993;88:34-38.
  9. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterol 1992;103:1732-1738.
  10. Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before heller myotomy results in worse outcomes than heller myotomy alone. Ann Surg 2006;243:579-586.