Cáceres Corner Case 199 – SOLVED!

Dear Friends,
Today´s case is provided by my good friend Alberto Villanueva.

PA radiograph belong to a 58-year-old man with cough and weight loss. Gastrectomy for stomach cancer in 2006. A previous film is shown for comparison.

Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images shown on Monday

Dear Friends,

showing a PA chest radiograph taken three months later.

What do you see?

Click here to see the new image

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Findings: PA radiograph taken in February 2018 shows an area of increased opacity in the subcarinal region (A, red arrows), more evident when compared with a previous film of 2014 (B). This finding was not detected.

Three months later the patient returned with increasing dyspnea. PA chest radiograph shows the typical appearance of RLL collapse, evidenced by a basal triangular shadow (C, arrow), downward hilar displacement (C, yellow arrow) and tracheal displacement. The subcarinal mass is now more evident (C, red arrow). Enhanced coronal CT shows the central mass (D, red arrows) as well as the RLL collapse (D, arrow).

Final diagnosis: oat-cell tumor of the lung

Congratulations to Elisa and Krister A, who were the first to detect the subcarinal mass in the initial examination
 
Teaching point: most of you detected the subcarinal mass that was missed in the original reading. This case emphasizes the importance of comparing with previous films to detect subtle findings.

Cáceres Corner Case 198 – SOLVED!

Dear Friends,

Today I’m presenting chest radiographs of a 28-year-old man with severe headache and high blood pressure (201/110 mmHg).

What do you see?

Click here to see the see the images


NEW CLINICAL INFORMATION:

Pulses were weaker in the lower extremities.

Click here to see the see the answer

Findings: Chest radiographs show a moderate cardiomegaly. There is pulmonary vascular redistribution, with the upper vessels (A, red circles) larger that the lower ones (A, blue circles), indicating an early stage of left cardiac failure.
The information of weak pulses in the lower extremities is important. This finding suggests impeded blood flow in the thoracic aorta, the most common cause being aortic coarctation. The small aortic knob and the lack of rib notching go against it, though.

CT angiogram shows narrowing and complete interruption of the distal thoracic aorta (C-E, circles), with abundant collateral circulation. The mid-aortic syndrome usually happens in children and young adults. The etiologies vary. In this particular case, biopsy confirmed Takayasu arteritis.

An aortic graft was placed to circumvent the obstruction (F-G, arrows).

Final diagnosis: Mid-aortic syndrome secondary to Takayasu arteritis
 
Congratulations to Ner, who made the correct diagnosis and to Krister A who was the first to suggest aortic obstruction.
 
Teaching point: in a young person with severe hypertension, distal pulses should be checked. If weak, aortic coarctation should be suspected. If the telltale signs of coarctation are missing, mid-aortic syndrome should be considered.