* Since 1 day periumbilical pain radiating to RLQ.
* CRP 75, leucocytes 18.000.
What do you see? Appendicitis? Diverticulitis?
presenting chest radiograph of a 77-year-old man with malaise and weight loss.
What do you see?
This is the last case before the summer. Will see you again in September. Enjoy your vacation!
Findings: PA radiograph shows increased opacity of the left hilum (A, arrow), which is due to a mass projected over it, as seen in the lateral view (B, arrows). In addition, there is convexity of the aortopulmonary window (A, red arrow)
The increased hilar opacity (C, arrow) was not visible in a PA radiograph taken six months earlier (D, circle). Convexity of the aortopulmonary window (C, red arrow) was not present at that time.
In the lateral view, the mass (E, arrows) was visible six month earlier, albeit smaller (F, arrow). This progression indicates rapid growth.
Enhanced axial and coronal CT confirms a pulmonary mass invading the aortopulmonary window (G and H, arrows). Lung metastases were present (insert, red arrows)
Diagnosis: lung carcinoma invading the aortopulmonary window
I am presenting this case to discuss the aortopulmonary window (APW), which is a small mediastinal space located between the aortic knob and the pulmonary artery in the PA view (Fig 1A). The APW is normally concave; convexity (Fig 1B) suggests an abnormality that should be studied with enhanced CT.
Visibility of the APW is difficult in the elderly, because the superimposed uncoiled descending aorta makes the interpretation more difficult (Fig 2).
Convexity of the APW may be overlooked unless we look specifically at the area (fig 3). The larger the abnormality, the more readily it is detected in the chest radiograph. Subtle changes are more difficult to identify and comparing with previous films is very helpful.
Causes that may alter the APW are: tumors, enlarged lymph nodes, aortic aneurysms and increased mediastinal fat. The phrenic nerve crosses this space and a phrenic neurinoma may also grow in the APW, although I have never seen a case.
Enlarged lymph nodes are by far the most common cause of occupation of the APW. They may occur in malignant and non-malignant diseases. They usually coexist with radiographic manifestations of the primary process (Figs 4 and 5).
In isolated occupation of the APW the etiology cannot be determined in the chest radiograph and enhanced CT should be obtained (fig 6).
Aortic aneurysm is an uncommon cause of convexity of the APW (Fig 7). The abnormality is initially subtle and it becomes more evident as the aneurysm grows (Fig 8).
Radiographs taken five years earlier did not show the abnormality (E and F, circles).
Enhanced axial and coronal CT demonstrate that the mass represents a saccular aneurysm arising from the aortic arch (G and H, arrows).
Comparison with previous films shows a normal APW in 2007 and progression of the opacity over a three-year period (arrows).
Enhanced CT shows that the opacity represents a partially thrombosed aneurysm arising from the inferior aspect of the aortic arch (C-D and E, arrows).
Last but not least, we should remember that mediastinal fat is an innocuous cause of convexity of the APW (Fig 9).
Follow Dr. Pepe’s advice:
1. Convexity of the APW suggests underlying pathology.
2. Enlarged lymph nodes are the most common cause of a convex APW.
3. Aneurysm and mediastinal fat may also enlarge the APW
Presenting today radiographs of a 65-year-old man with back pain.
What do you see?
Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.
A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).
I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).
In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
Final diagnosis: Carcinoma of esophagus with bone metastases
Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.
Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!
We present the case of a 31-year-old woman with:
* Nausea and vomiting since three days
* Unable to eat or drink without vomiting
* Epigastric pain after eating
* Feels weak
* No prior trauma or illness
* No fever, no diarreha, no hematemesis or bloody stools
* No other family members ill
See below the laboratory findings:
What do you think?
Signs of dehydration with secondary acute renal impairment and electrolyte disorders
Abdominals X-Ray were performed:
What do you see on the X-Rays?
* Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border
* Air – fluid level at the right upper quadrant: free air?
* Colonic air at the right upper quadrant (Chilaiditi)
* Apparent soft tissue mass at the right upper quadrant
* No apparent dilated bowel loops
* Elongated right liver lobe (Riedel lobe)
* Instability of the symphysis pubis
* Subphrenic abscess
* Hepatic abscess
* Anterior interposition of colon to the liver
* Loculated pneumothorax (mimick)
* Situs inversus – gastric air (mimick)
* Pneumobilia, portal venous gas (smaller amount)
Images from an abdominal CT-scan:
What do you see on the CT images?
* Anterior defect in the right hemidiaphragm
* Partial herniation of stomach and transverse colon
* Gastric outlet obstruction due to compression of the pyloric region of the stomach, with secundary dilatation with fluid
* Normal position of the gastro-esophageal junction and hiatus
* No signs of ischemia
* Collapse of the right middle lobe and partial collapse of the right lower lobe.
What is the most likely diagnosis?
Morgagni hernia of the diaphragm
Patient had a laparoscopic reduction of the hernia with mesh closure of the defect. No signs of ischemia at surgery.
Uneventful recovery with resolution of pain and normal intake the day after.
* Rare congenital diaphragmatic hernia (<5% of all CDH)
* Anterior (retrosternal)
* Right-sided (90%)
* Usually small
* +/- 30% symptomatic: respiratory distress (newborn), recurrent chest infections, abdominal symptoms
* Contents: omental fat, transverse colon (60%), stomach (12%)
* Treatment: surgical repair
> In symptomatic cases, some say also in asymptomatic cases: prevention of strangulation of hernia contents
* Differential diagnosis:
> Traumatic diaphragmatic rupture
> Diaphragmatic eventration / weakness / paralysis (abnormal contour / position of the dome)
> Cardiophrenic angle lesions ( pericardial fat pad, cyst, lipomatosis, tumor)
Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?
More images will be shown on Wednesday.
showing today axial and coronal CT.
What do you think?
Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.
Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).
In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).
13-year-old girl with knee pain for 2 months.
What do you see?
Periphyseal (both knees) hyperintensity on sagittal fat suppressed T2 Weighted image (a) and Proton Density Weighted image (b) and hypointensity on sagittal T1Weighted image (c) (arrows).
FOPE: Focal periphyseal edema
– Mostly around the knees
– Both genders can be affected during skeletal maturation
– Painful manifestation of physiologic physeal fusion