Chest imagingCase Type
Filipa de Sousa Costeira, Filipa Vilaverde, Andre Oliveira, Carolina Leite;
Hospital de Braga,
13 years, female
A 13-year-old girl was found unconscious underwater, with unknown duration of submersion. The history of previous trauma was unknown. She required reviving with external cardiac massage and intubation at site.
Upon admission she was conscious and agitated, with evidence of respiratory distress. CT scan was performed.
The patient was admitted to an intensive care unit, with need for mechanic ventilation. She had progressive clinical improvement and, after 2 days, no longer required oxygen therapy. The patient completed 10 days of amoxicillin and clavulanic acid. Upon medical release, she showed no deficits.
After 3 months, she was reevaluated in external consultation, showed no symptoms and chest X-ray was then unremarkable.
Cerebral CT scan was unremarkable.
Thoracic CT scan showed bilateral, diffuse ground-glass areas and airspace consolidation, mainly in the superior aspect of the inferior lobes (Fig. 1, 2).
A chest X-ray was performed before medical release, 10 days after the initial evaluation, and revealed a few bilateral residual densifications.
After 3 months, reevaluation chest X-ray was unremarkable (Fig. 3).
In 2002, the WHO defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid.
It represents respiratory impairment in case of submersion or immersion. If the process of drowning is interrupted, it is termed nonfatal drowning.
Drowning is a leading cause of death worldwide between 5 and 14 years of age, particularly in boys. 
The main consequence of prolonged submersion is adequate ventilation exchange impairment due to laryngospasm and aspiration of water or foreign material, leading to hypoxaemia and acidosis. Water and foreign material aspiration leads to endothelium and pneumocytes damage, with increased surfactant production, resulting in diffuse alveolar damage. If the situation persists, it can evolve into respiratory distress syndrome (ARDS).
Hypoxia is the central cause of diffuse organ pathology in case of drowning. 
Chest radiographic findings in these cases are well described in the literature. However, reports of CT features are scarce. 
Chest radiography is important for distinguishing patients with and without aspiration and allows evaluation of therapy response and possible complications. Initially it can be normal, even in patients with clinical evidence of pulmonary oedema. When it is abnormal, the most common finding is perihilar or generalised pulmonary oedema. Foreign material aspiration can lead to sand bronchogram, with radiodense material in the tracheobronchial tree.
CT findings include bilateral patchy or diffuse areas of ground-glass attenuation and fine reticular opacities (“crazy-paving” appearance). Ill-defined centrilobular nodules may be found, as well as air-space consolidation. A central distribution of ground-glass attenuation is more common. [3, 4]
Pulmonary oedema in near-drowning is secondary to hypoxic pulmonary damage and usually resolves within three to five days. 
Alert mental status in the emergency room is predictive of survival in a near-drowning victim, whereas coma is suggestive of a poor outcome. 
Imaging plays an important role in the evaluation of near-drowning cases, allowing the characterisation of the lesions’ extension as well as a possible identification of the cause. During follow-up, it may be helpful if the patient has recurrent or persistent symptoms, but is not formally required.
Written informed patient consent for publication has been obtained.
David Szpilman, Joost J.L.M. Bierens, Anthony J. Handley, James P. Orlowski (2012) Drowning. N Engl J Med 366:2102-2110 DOI: 10.1056/NEJMra1013317 (PMID: 22646632)
 Orlowski JP, Abulleil MM, Phillips JM (1989) The hemodynamic and cardiovascular effects of neardrowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med 18:104
 Tim B. Hunter, Walter M. Whitehouse (1974) Fresh-Water Near-Drowning: Radiological Aspects. Diagnostic Radiology 112(1) (PMID: 4832512)
 Kim, Kun-Il; Lee, Ki Nam; Tomiyama, Noriyuki; Johkoh, Takeshi; Ichikado, Kazuya; Kim, Chang Won; Lee, Suk Hong (2000) Near Drowning: Thin-Section CT Findings in Six Patients Journal of Computer Assisted Tomography: 24(4):562-566 (PMID: 10966187)