Archives of Cardiovascular Disease (2009) 102, 75—76

IMAGE Westermark’s sign

Le signe de Westermark

Erwin Chiquete a,∗, Jorge Corona b, Carlos Guarena˜ a, Juan Gutiérrez-Manjarrez a, Carolina Torres-Anguiano a, Ernesto Landeros a, Mario Paredes-Espinosa a

a Servicio de Medicina Interna, Hospital Civil de Guadalajara ‘‘Fray Antonio Alcalde’’, Hospital 278, Universidad de Guadalajara, 44280 Guadalajara, Jalisco, Mexico b Department of Radiology, Hospital Civil ‘‘Fray Antonio Alcalde’’, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico

Received 27 May 2008; received in revised form 4 June 2008; accepted 19 June 2008 Available online 18 September 2008

A 50-year-old obese woman presented to the emergency department with a 1-day his- tory of nonproductive cough and severe pleuritic chest pain. On physical examination the KEYWORDS patient was dehydrated and dyspneic, presented bilateral fine basal crackles, dilated vari- Chest film; cose veins in both legs and tenderness on compression of the calves. Arterial blood gas CT scan; analysis showed a pH of 7.47, PaCO of 32 Torr and PaO of 77 mmHg. The electrocardio- Pulmonary embolism; 2 2 gram demonstrated profound Q waves in DIII and inversion of the T waves in DIII and from Radiology; V1 to V4. A chest radiograph showed focal oligemia (Westermark’s sign) in the left lung Tomography; (Fig. 1A). Coagulation tests revealed an increased fibrinogen concentration and a D-dimer Westermark’s sign concentration of 3.0 ␮g/ml (normal value less than 1.0 ␮g/ml). A computed tomography angiogram showed marked avascularity of the left lung field (Fig. 1B) and a large thrombus located at the left pulmonary artery bifurcation (Fig. 1C and D). MOTS CLÉS Focal avascularity of lung fields on the chest radiograph is known as Westermark’s Radiographie sign [1—3]. While it has been regarded as a good predictor of pulmonary embolism thoracique ; (PE) (specificity of 92%) [2], it has a rather low sensitivity (14%) [2], thus limiting CT scan ; its utility in determining which patients have PE. Although over 80% of patients with Embolie pulmonaire ; confirmed PE have an abnormal chest X-ray at initial evaluation [2,3], plain films Radiologie ; have been superseded by modern imaging techniques, and they have been placed as Tomographie ; a part of the basic preliminary testing. Differential diagnosis of Westermark’s sign Signe de Westermark may include cardiac and pulmonary conditions [4]. Among cardiac causes of reduced

∗ Corresponding author. Fax: +52 33 3614 1121. E-mail address: [email protected] (E. Chiquete).

1875-2136/$ — see front matter © 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.acvd.2008.06.010 76 E. Chiquete et al.

Figure 1. A. Chest X-ray film showing left lung oligemia (Westermark’s sign); right hilar and basal infiltrates are also evident. B. Thoracic contrasted CT scan demonstrating the extensive filling defect of the left pulmonary artery branches. C and D. Thoracic contrasted CT scan showing a large thrombus on the pulmonary artery bifurcation.

filling of the pulmonary vessels are tetralogy of Fallot, References Ebstein’s anomaly, tricuspid atresia and Eisenmenger com- plex. Lung conditions that may yield false positives because [1] Westermark N. On the roentgen diagnosis of lung embolism. Acta of a hyperlucent field include pulmonary emphysema, uni- Radiol 1938;19:357—72. lateral air trapping and Swyer-James syndrome, among [2] Stein PD, Terrin ML, Hales CA, Palevsky HI, Saltzman HA, others. Technical circumstances may result in incorrect Thompson BT, et al. Clinical, laboratory, roentgenographic, and interpretation of this sign, and include an overexposed electrocardiographic findings in patients with acute pulmonary embolism and no preexisting cardiac or pulmonary disease. radiograph, a noncentered beam, an asymmetrical chest Chest 1991;100:598—603. wall and unilateral marked subcutaneous emphysema. It [3] Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, is preferable to obtain the chest film while the patient is Ravin CE. Chest radiographic findings in patients with acute standing and with a posterior—anterior well-centered beam. pulmonary embolism: observations from the PIOPED study. Radi- Furthermore, Westermark’s sign may also be present in cases ology 1993;189:133—6. of chronic or recurrent embolisms [4]; thus, in diagnosing [4] Reed JC.Chest radiology: Plain film patterns and differential acute PE, comparative films may be recommended. diagnoses. 3rd ed. St Louis, MO: Mosby year book; 1991. p. 311.