A 70-year-old female:
– With pain LLQ
– CRP 142
– Leucocytes 20.000
What is your diagnosis? Appendicitis? Diverticulitis?
this is the last case of the first semester. Will meet again in September.
Wish all of you a very happy summer vacation!
This is a new “art of interpretation” case. Radiographs belong to a 40-year-old woman with mild cough.
What do you see?
1. Chronic TB changes
2. AV malformation
3. Bronchial atresia
4. Any of the above
To refresh your memory, remember that interpreting a chest radiograph involves three basic steps:
1. Gather information. Examine the radiographs carefully and collect all the pertinent information. Remember that overlooking visible findings is the main cause of errors.
2. Analyze the findings. Once collected, the findings should be properly evaluated, and an opinion should be offered.
3. Decide on the next step to reach the diagnosis.
In this patient the lateral view is unremarkable.
All relevant findings are seen in the PA radiograph:
1. Tubular branching opacities in the left upper lung (A, red arrows)
2. Increased lucency of left upper lung (A, circle)
3. Negative finding: the left hilum is in its normal position.
1. Branching tubular opacities have a limited differential diagnosis: either they are pulmonary vessels or mucous-filled dilated bronchi.
2. Hyperlucent lung is a reliable sign of lung disease when complemented with an expiration film to demonstrate air-trapping.
3. The normal position of the left hilum is a negative finding that excludes a fibrotic process in the LUL (I.e. chronic TB), which should cause upper retraction of the hilum.
The combination of a lucent lung lesion with branching tubular opacities points towards an obstructive process of a segmental bronchus with mucous impaction (Obstruction of a lobar bronchus would cause lobar collapse instead of increased lucency).
Once segmental bronchial obstruction is suspected in the chest radiograph, the best procedure to confirm it is an enhanced chest CT with expiratory views. In this case it shows attenuated upper lobe vessels (B, arrows) and obvious mucous impactions (B-C, red arrows).
Axial CT with lung window confirms the increased lucency of the apical-posterior segment of the RUL (D, circle)
Inspiration/expiration axial CT views (E-F) confirm segmental air trapping on the left.
Bronchoscopy did not show any inflammatory or tumoral changes in the LUL bronchus. The orifice of the apical-posterior segment was missing.
Final diagnosis: bronchial atresia of apical-posterior segment of LUL
In my experience, bronchial atresia is the most common congenital lung malformation seen in adults. Congenital bronchial atresia results from proximal interruption of a segmental bronchus, which causes overinflation of the affected segment and secondary mucus impaction. Chest radiography shows a focal hyperlucent area with internal mucus impaction. CT depicts these findings to better advantage. Inspiration and expiration views help to confirm air-trapping. In case of doubt, bronchoscopy excludes other causes of bronchial obstruction.
Congenital bronchial atresia may present different appearances, as shown in the following case of one of our X-ray technicians.
30-year-old female, asymptomatic. PA chest radiograph (A) shows hyperlucent left lung with discrete dextroposition of the heart. Expiration film (B) shows air-trapping on the left with deviation of the mediastinum towards the right. Note a thick tubular shadow in the left lower lung (A-B, red arrows), compatible with bronchial impaction. The findings are suggestive of congenital bronchial atresia
Axial and coronal enhanced CT show increased lucency of the posterior segments of LLL with a central mucous impaction (C-D, red arrows)
Decreased vascularity of LLL and central mucous impaction (E-F, red arrows) are better demonstrated in the MIP reconstruction.
Coronal view eleven years later show that air is now present within the dilated bronchus, confirming the diagnosis (G-H, circles) .
Dr. Pepe’s teaching point:
Hyperlucent lung with mucous impaction are the hallmark of congenital bronchial atresia.
43-year-old healthy patient:
– with fibromyalgia
– No other relevant medical history
What do you see on the following images?
Multiple focal sclerotic bone lesions clustered around joints in both knees and sacroiliac joints
Sclerosing bony dysplasia characterized by multiple enostoses
Typically clustered around joints, aligned parallel to trabeculae. Usually 1-3 mm, they can reach up to 20 mm
Rare condition; inherited; asymptomatic; incidental
Important to avoid misdiagnosis with other relevant pathologies such as metastasis
Today’s radiographs belong to a 24-year-old woman with cough and fever. What do you see?
More images will be shown next Wednesday and the answer will be published on Friday.
Showing today CT images of the chest. What do you think?
Findings: Chest radiographs show air-space disease in the right lower lobe (A-B, arrows). There is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.
Axial CT with lung window shows RLL air-space disease without cavitation (C, arrow). Mediastinal window at different levels confirms enlarged paratracheal, subcarinal and neck lymph nodes with hypodense center (D-F, red arrows). These findings should suggest active tuberculosis as the first possibility.
Although TB usually affects upper lobes, isolated involvement of lower lobes occurs in about 7% of cases.
Mycobacterium tuberculosis was found in the sputum.
Final diagnosis: active TB.
Congratulations to Archanareddyt who was the first to make the diagnosis.
Teaching point: lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should be tuberculosis.
What do you see on these images?
CT scan shows a large calcified lesion. MRI shows a large cortical-based high T2 lesion with cystic component and dark T2 foci corresponding to the calcifications. Post-contrast images show patchy enhancing areas.
DNET (usually may calcify) ganglioglioma (cystic areas, enhancing solid component, may calcify).
The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.
1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above
What do you think? Come back on Friday to see the answer!
Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.
Final diagnosis: superimposed hair braid simulating pulmonary disease
The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.
I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:
1. Nipples and skin lesions
2. Hair and/or hair implements
Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.
Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)
Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.
Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).
In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).
In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.
Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).
Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)
To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)
Follow Dr. Pepe’s advice:
1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.
* Severe pain abdomen
* Tender abdomen
* Clinical ileus
Mechanical ileus with caliber change in ileum. Distended stomach with air in the major curvature of the wall, with air bubble outside lumen, suspect for pneumatosis intestinalis. Extended air in left portal vein branches and in central portal vein (portal venous gas peripheral, gas in bile ducts central).
Today’s case has been provided by my good friend Victor Pineda. Radiographs belong to a 36-year-old man with cough and fever. For comparison, I am including radiographs taken nine years earlier.
1. Chronic TB changes
2. Endobronchial lesion
3. Congenital lesion
4. None of the above
What do you see? More images will be shown on Wednesday. Come back on Friday to see the answer.
Showing coronal and axial CT images. What do you think?
Findings: Pa radiograph shows a left ill-defined opacity that blurs the upper mediastinal contour (A, arrow) and the lower cardiac border (A, red arrow). In the lateral view there is a retro-sternal line that goes from top to bottom (B, arrows). The appearance is typical of marked LUL collapse, which has not changed in the last nine years. Therefore, the most likely diagnosis is a benign condition that occludes the origin of the LUL bronchus.
Enhanced axial and coronal CTs show marked irregularity of the origin of the LUL bronchus (C, arrow) due to a large mass with coarse calcification (C-D, circles) causing distal lobar collapse. The most likely diagnosis is a benign tumor, either carcinoid or hamartoma. Given the size of the mass and the higher frequency of carcinoid, I would favor this diagnosis. It was proved by biopsy and surgery.
Final diagnosis: endobronchial carcinoid with LUL collapse
Congratulations to Ahmed Al Ani who was the first to suggest the correct diagnosis in the plain film.
Teaching point: Detecting LUL collapse in chest radiographs is important because the great majority are secondary to bronchogenic carcinoma. This patient was lucky.
* Presents with a mass around knee which has been present for seven years and has been enlarging since then
A sclerotic ill-defined soft tissue mass around the knee was present on radiographs.
The mass is located in the soft tissue around the knee with no apparent bone destruction.
Coronal fat-suppressed T2 WI (a) shows a hyperintense lobulated mass which was hypointense on T1 WI (b) and has peripheral heterogeneous enhancement on postcontrast T1 WI (c); cortical bone is preserved.
The mass encircles a pedunculated lesion which continues with cortical and medullary bone (arrows), consistent with an osteochondroma.
Histopathologic diagnosis of the mass is chondrosarcoma.
* Osteochondromas are developmental lesions rather than true neoplasms and are often referred to as an osteocartilaginous exostosis (or simply exostosis).
* An osteochondroma is composed of cortical and medullary bone protruding from and continuous with the underlying bone; cortical and medullary continuity between the osteochondroma and parent bone is well depicted on MRI.
* Malignant transformation, almost invariably due to chondrosarcoma arising in the cartilage cap of the lesion, occurs in approximately 1% of solitary osteochondromas.
* Lesions that grow or cause pain after skeletal maturity should be suspected of malignant transformation since osteochondromas only rarely enlarge after this time.
In the aftermath of the Covid-19 scare, I have elected to show a new “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.
Take your time before seeking the answer.
This case starts with PA and lateral chest radiographs of a 63-year-old man with acute chest pain. Would you suspect pulmonary embolism?
3.Need a CT
Findings: the most significant finding is a broad right descending pulmonary artery (A, arrow) with an abrupt cut-off (A, red arrow), a sign of embolus in the artery (Palla sign). Oligemia of the right lung is also visible (Westermark sign). Both signs are suggestive of pulmonary embolism, to be confirmed with enhanced CT.
An enlarged azygos vein is also seen (A, yellow arrow), as well as a bump in the para-aortic line (A, blue arrow)
Enhanced CT confirms multiple pulmonary emboli (C, arrows) as well as a large embolus in the right descending pulmonary artery responsible for the Palla sign (D, red arrow)
Caudal slices show a non-enhancing opacity in the lower mediastinum. What would be the most likely diagnosis?
4- Any of the above
Findings: the serpiginous appearance of the opacity (E-F, red arrows) is compatible with all three diagnosis. Mediastinal varices are the most likely diagnosis because they are not unusual, and the top of the spleen appears to be enlarged (F, asterisk).
The varices are not opacified because the images were taken during the arterial phase.
Late images taken during the venous phase show enhancement of the varices (G, arrow). Coronal reconstruction confirms the splenomegaly and a whorl of varices (H, arrow) responsible for the bump of the para-aortic line in the PA radiograph. The varices (V) drain into an enlarged azygos vein (I, arrow). The increased flow explains the prominent azygos in the PA chest film.
Review of the clinical history discovered that the patient had cirrhosis of the liver.
Final diagnosis: mediastinal varices in a patient with liver cirrhosis and pulmonary embolism
Paraesophageal varices are not uncommon and are secondary to portal hypertension in patients with hepatic cirrhosis. When enlarged, they are visible as a lower middle mediastinal mass in about 8% of chest radiographs of cirrhotic patients.
They may be misdiagnosed in CT studies because they don´t enhance in the arterial phase, as happened in the case presented and in a second case shown below.
58-year-old man with liver cirrhosis. PA radiograph shows widening of lower mediastinal lines, which are slightly undulated (A, arrows). There is increased opacity of the left upper quadrant of the abdomen and the lateral wall of the stomach is indented, suggesting splenomegaly. On the lateral view there is increased opacity of the middle lower mediastinum, with a suggestion of tubular structures (B, circle).
Enhanced axial CT (arterial phase) shows a non-enhancing mass in the middle mediastinum that looks like a cyst (C, arrows). Venous phase demonstrates multiple enhanced veins within the mass (D, arrows). The cirrhotic liver and the enlarged spleen are visible in the coronal CT (E) .
Dr. Pepe’s teaching points:
Remember that the mediastinum is composed mainly of vascular structures. When a mediastinal abnormality is present, always rule out a vascular origin (arterial or venous).