Detective work

A teenage girl attended the X-ray department for cough. A chest radiograph acquired show some patchy consolidation in the left upper lobe.

But on second look, the left hemidiaphragm is higher than the right (normally the reverse is true). Plus also the normal gastric bubble expected just under the left hemidiaphragm is not visualized.













This leads to an ultrasound which shows a large cystic mass in the abdomen with "snow-storm" appearance. As the mass is too big to be assessed using ultrasound, patient was scheduled for MRI.










MRI shows a huge cystic lesion arising from an enlarged spleen. A diagnosis of haemorrhagic splenic cyst was made. Patient was referred for surgical intervention.

The lesson of this encounter is to be vigilant of the normal radiographic presentation of expected normal anatomy in normal population. In the initial chest radiograph, it is known that the left hemidiaphragm should be lower than the right in an erect X-ray due to the gravitational effect of the heart 'sitting' on the left diaphragm. In certain cases however, the left diaphragm maybe of equal level or higher than the right due to presence of underlying bowel gases (in the stomach or colon) pushing the diaphragm up. However, in the case presented here, there is no distended hollow viscus underneath the left hemidiaphragm, making the suspicious of an underlying solid mass valid.

MRI and ultrasound are preferred in the radiological investigation of paediatric age group due to lack of ionizing radiation. For MRI, most abdominal MRI scans require administration of Gadolinium contrast media. Thus patient with known allergy to Gadolinium or other substances may need to be premedicated with oral prednisolone of up to 40mg 12 hours and 40mg 2 hours before the study. Ultrasound preparation is as per adult, i.e. 6 hours fasting for older children or skipping a meal for infants. The purpose of fasting in ultrasound scan is to reduce bowel gas which will interfere with the scan.