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

IMAGE

Westermark’s sign
Le signe de Westermark

Erwin Chiquete a,∗, Jorge Corona b, Carlos Guareña 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, PaCO2 of 32 Torr and PaO2 of 77 mmHg. The electrocardio-
Pulmonary embolism;
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Radiologie ; have been superseded by modern imaging techniques, and they have been placed as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: erwinchiquete@runbox.com (E. Chiquete).

1875-2136/$ — see front matter © 2008 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.acvd.2008.06.010
76
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,
Ebstein’s anomaly, tricuspid atresia and Eisenmenger com-
plex. Lung conditions that may yield false positives because
of a hyperlucent field include pulmonary emphysema, uni-
lateral air trapping and Swyer-James syndrome, among
others. Technical circumstances may result in incorrect
interpretation of this sign, and include an overexposed
radiograph, a noncentered beam, an asymmetrical chest
wall and unilateral marked subcutaneous emphysema. It
is preferable to obtain the chest film while the patient is
standing and with a posterior—anterior well-centered beam.
Furthermore, Westermark’s sign may also be present in cases
of chronic or recurrent embolisms [4]; thus, in diagnosing
acute PE, comparative films may be recommended.
E. Chiquete et al.
References
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