Hrev_master Abstract Lung ultrasound is an expanding field and is becoming a stan- dard of care. Its various bedside applications have modified many diagnostic paths from the newborn to the geriatric patient. In this case report, we describe and show a new sign of the lung ultra- sound semeiotics, the push-out sign. Case Report A 55-year-old woman came up to our general practice office complaining about a cough which had lasted for two weeks. She was in good general condition and she had no fever or other major symptoms. Physical examination revealed a deformation of the thorax: a well-circumscribed oval shaped bulge was evident during cough- ing in the eighth intercostal space of the left mid-axillary region. The chest wall bulge was soft and tender at palpation and wasn’t apparent during normal respiration but it was easy to detect during cough or Valsalva maneuver (Supplementary file A). The patient did not report any recent traumatic event, but had underwent a hysterectomy 7 years earlier for a low-grade uterine mixoid leiomyosarcoma. One year before our visit, a follow up positron emission tomography/computed tomography (CT) showed new focal hyper- captation of suspected neoplastic nature in the posterior segment of the left lower pulmonary lobe. A mini-thoracotomy was performed and the pulmonary parenchyma resulted free from neoplastic infil- tration. A chest ultrasound just over the bulge showed the lung and pleura moving externally with expiration and internally with inspi- ration (Figure 1). We also registered ultrasound images of the lung herniation during a Valsalva maneuver (Supplementary file B). We sent the patient for a chest X-Ray by which it wasn’t pos- sible to identify the hernia. Because of the relatively young age of the patient and the amount of radiation absorbed during the previ- ous year, we decided not to proceed with a CT scan1 to confirm the already evident diagnosis. Discussion Lung herniation is defined as a protrusion of the lung parenchyma with pleural membranes through a defect of the tho- racic wall. The first published description dates back to 1845 when Morel-Lavallée collected 32 cases.2 Lung herniation may be clas- sified as congenital, traumatic or post-thoracotomy. Hernia after cardio-thoracic procedures is an uncommon entity.3 A single insti- tution retrospective review of patients submitted to thoracic sur- gery identified it in only 16 patients over 10 years.4 In the case we describe, the cough effort, increasing intratho- racic pressure in a zone of greater laxity, determined the emergence of the hernia well over a year after surgery.5 Controversy still exists concerning the role of surgical repair and at the moment our patient is asymptomatic and the manage- ment is conservative. Emergency Care Journal 2018; volume 14:7808 Correspondence: Luca Iaboli, General Practice, Azienda Unità Sanitaria Locale di Modena, Via S. Giovanni del Cantone 23, 41121 Modena, Italy. Tel.: +39.053629562. E-mail: liaboli@hotmail.com Key words: Lung ultrasound; Lung herniation; Push-out sign. Contributions: LI formulated the ultrasound diagnosis and wrote the ini- tial draft. All authors searched the literature, made critical revisions, and approved the final version. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Received for publication: 6 September 2018. Revision received: 9 October 2018. Accepted for publication: 30 October 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright L. Iaboli et al., 2018 Licensee PAGEPress, Italy Emergency Care Journal 2018; 14:7808 doi:10.4081/ecj.2018.7808 Ultrasound diagnosis of lung herniation: The push-out sign Luca Iaboli,1 Luca Baldini,2 Roberto Galassini,1 Roberto Copetti3 1General Practice, Azienda Unità Sanitaria Locale di Modena; 2Radiology Department, Azienda Ospedaliero-Universitaria di Modena, Ospedale Civile di Baggiovara; 3Emergency Department, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Trieste, Italy Figure 1. (A) Normal ultrasound image of the lung: pleura can be seen in between and under the ribs; (B) the push-out sign: pleura is now visualized out of the ribs. [Emergency Care Journal 2018; 14:7808] [page 129] Non -co mmerc ial us e o nly [page 130] [Emergency Care Journal 2018; 14:7808] Conclusions The diagnosis of lung herniation is usually possible after an accurate history and a clinical examination showing the typical bulge which changes with respiration or with the cough. A confir- mation may come from chest sonography. In this case report we described a new lung ultrasound sign which is pathognomonic for lung herniation and which we named the thoracic push-out sign. References 1. Detorakis EE, Androulidakis E. Intercostal lung herniation – The role of imaging. Radiol Case 2014;8:16-24. 2. Morel-Lavallée A. Hernies du poumon. Bull Soc Chir Paris 1845-1847;1:75-195. 3. Afzal MR, Wilson JH. Images in clinical medicine. Lung her- niation after cardiac surgery. N Engl J Med 2013;368:e35. 4. Athanassiadi K, Bagaev E, Simon A, Haverich A. Lung herni- ation: a rare complication in minimally invasive cardiothoracic surgery. Eur J Cardio-thoracic Surg 2008;33:774-6. 5. Asenjo M, Angelina M. Images in clinical medicine. Lung her- niation with coughing. N Engl J Med 2015;372:464. Images in Emergency Non -co mmerc ial us e o nly