A 58-year-old man with a history of COPD presents to the emergency department with acute onset pleuritic chest pain, dyspnea, and scant hemoptysis. CT pulmonary angiography (CTPA) is performed. The structure marked **A** in the diagram shows a pleural-based wedge-shaped opacity with its apex directed toward the hilum. Which of the following best explains the pathophysiology underlying this radiological finding?
A. Acute exacerbation of COPD with mucus plugging and atelectasis of the lower lobe bronchus
B. Consolidation secondary to aspiration pneumonia with subsequent pleural involvement and abscess formation
C. Spontaneous pneumothorax with compression of lung parenchyma and pleural adhesions
D. Pulmonary embolism lodged in a subsegmental or peripheral pulmonary artery with insufficient collateral circulation from bronchial arteries, leading to tissue infarction
Explanation
Why option 1 is correct
The pleural-based wedge-shaped opacity with apex pointing toward the hilum is the classic Hampton hump, the pathognomonic radiological sign of pulmonary infarction on CTPA. This finding develops in 10–30% of patients with pulmonary embolism (PE) when emboli lodge in subsegmental or peripheral pulmonary arteries where collateral circulation from bronchial arteries is insufficient. The patient's COPD history is a significant risk factor, as compromised bronchial collateral supply in chronic cardiopulmonary disease predisposes to infarction. The clinical presentation of pleuritic chest pain, hemoptysis (classically scant and dark), and dyspnea is classic for pulmonary infarction complicating PE. [Fleischner Society 2024; ACCP CHEST 2024 PE Guidelines]
Why each distractor is wrong
Option 2 (Aspiration pneumonia): Aspiration pneumonia typically presents as consolidation in dependent lung zones (right lower lobe when supine) but lacks the characteristic wedge shape with apex toward hilum and is not associated with hemoptysis in the acute setting. The clinical context of acute pleuritic chest pain and hemoptysis in a patient without aspiration risk is inconsistent.
Option 3 (COPD exacerbation with atelectasis): While COPD exacerbation can cause consolidation, it does not produce the classic pleural-based wedge-shaped opacity with hilar apex (Hampton hump). Atelectasis from mucus plugging is typically linear or subsegmental, not wedge-shaped, and hemoptysis is not a feature of uncomplicated exacerbation.
Option 4 (Spontaneous pneumothorax): Pneumothorax presents as a lucency (air in pleural space) with a visible visceral pleural line, not an opacity. It does not cause wedge-shaped consolidation or hemoptysis, and the clinical presentation is inconsistent with this diagnosis.
High-YieldNEET PG
Hampton hump = pleural-based wedge opacity with hilar apex in PE with infarction; occurs in 10–30% of PE cases, especially with subsegmental emboli and compromised bronchial collaterals (prior cardiopulmonary disease).
[Fleischner Society 2024; ACCP CHEST 2024 PE Guidelines]
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