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| CME IN IMAGE |
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| Year : 2021 | Volume
: 19
| Issue : 4 | Page : 300-301 |
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Continuous diaphragm sign
Ajay Mathur, Bhawani Shankar Jandu, Suresh Kumar Nitharwal, Hans Raj Pahadiya
Department of Medicine, SMS Medical College, Jaipur, Rajasthan, India
| Date of Submission | 09-Jul-2021 |
| Date of Decision | 23-Jul-2021 |
| Date of Acceptance | 26-Aug-2021 |
| Date of Web Publication | 07-Dec-2021 |
Correspondence Address:
Dr. Hans Raj Pahadiya
Assistant Professor, Department of Medicine, SMS Medical College, Jaipur
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_69_21
How to cite this article:
Mathur A, Jandu BS, Nitharwal SK, Pahadiya HR. Continuous diaphragm sign. Curr Med Issues 2021;19:300-1 |
A 75-year-old male presented with 5 days history of breathlessness, and facial and upper chest swelling. He had a history of chronic obstructive pulmonary disease for 15 years and was receiving treatment. On examination, his temperature was 37.6°C, blood pressure 110/76 mmHg, pulse 110 beats per min, respiratory rate 20 breaths per min, and oxygen saturation was 92% on room air. He had palpable cervical subcutaneous emphysema. On chest auscultation, there were bibasilar rales, and a Hammons crunch heard with each cardiac systole. He managed with supportive care, and discharged after 10 days on stable general condition.
| Questions | |  |
- What are the findings and sign seen on the chest radiograph and computed tomography (CT) scan?
- What are the differential diagnoses of this finding?
- What are other causes and complications of this condition?
Answers
- Frontal chest radiograph shows, a linear transverse lucency between the inferior border of the heart and the diaphragm resulting in the continuous appearance of the diaphragm, visualizing the central portion of the diaphragm in continuity with the lateral portions across midline (“Continuous diaphragm sign”) [Figure 1]a. Contrast CT scan images demonstrate a clear space between the inferior border of the heart and central part of the diaphragm (continuous diaphragm sign) which is clearly identified as air density on the lung window settings [Figure 1]b due to pneumomediastinum. Massive subcutaneous and inter-muscular emphysema, pneumomediastinum, and bilateral pneumothoraces with intercostal chest tube in situ on the right side are also noted [Figure 1]c
 | Figure 1: (a) Frontal chest radiograph shows, a linear translucency between inferior border of the heart and diagphrgam; (b) similar finding are noted in CT Chest image; (c) massive subcutaneous and inter-mascular emphysema, pneumo- mediastinum and bilateral pneumothoreces
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“Continuous diaphragm sign” is a radiological finding of pneumomediastinum. It is the presence of air lucency between the inferior surface of the heart and central portion of the diaphragm on frontal chest X-ray, resulting in visualization of the entire diaphragmatic contour across the midline. The central portion of the diaphragm is normally not visible on a frontal chest radiograph as it is obscured by the cardiac silhouette[1]
- Less commonly, aforementioned sign may also be seen with pneumopericardium. On radiographs, pneumopericardium typically appears as an isolated broadband around the heart. The alveolar rupture causes pneumomediastinum by leaking of gas along the bronchovascular interstitial sheaths into the mediastinum[2]
- Other common causes include trauma, invasive procedures, mechanical ventilation, airway obstruction, barotraumas, and pulmonary or pericardial infections.[2],[3] Most of the cases have a benign course and gradually recover without any complications. Serious complication includes tension pneumothorax, cardiac tamponade, and hypotension.[3],[4]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Levin B. The continuous diaphragm sign. A newly-recognized sign of pneumomediastinum. Clin Radiol 1973;24:337-8.  |
| 2. | Bejvan SM, Godwin JD. Pneumomediastinum: Old signs and new signs. AJR Am J Roentgenol 1996;166:1041-8. |
| 3. | Schmitt ER, Burg MD. Continuous diaphragm sign. West J Emerg Med 2011;12:526-7. |
| 4. | Bullaro FM, Bartoletti SC. Spontaneous pneumomediastinum in children: A literature review. Pediatr Emerg Care 2007;23:28-30. |
[Figure 1]
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