Elevated Hemidiaphragm and Shortness of Breath: Challenges in Clinicoradiologic Integration

Unilateral diaphragmatic paralysis is often suspected when a hemidiaphragm is found abnormally elevated on chest radiography. Chest radiography has a high sensitivity for diaphragmatic palsy. A 67-year-old male presented to the hospital with a history of 4 months of exertional breathlessness that improved after taking a rest. The patient had normal cardiac and respiratory physical function. He also had a normal electrocardiogram and good systolic function on echocardiography. A treadmill test revealed ST-segment changes during peak exercise and recovery phases. On chest X-ray, his right hemidiaphragm was shown to be significantly elevated. Further investigation was conducted to rule out diaphragmatic paralysis, and the findings took a surprising turn to an entirely different diagnosis.