Dr. Pepe’s Diploma Casebook: CASE 119

Dear Friends,

This week’s case follows the pattern of a Meet the Examiner presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer. And no peeking!


The chest radiographs belong to a 53-year-old man drug addict admitted after right pleural empyema was drained at another hospital.

What do you see?

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Findings: There is anterior pleural loculation with air after drainage (A and B, white arrows). There is also a thin-walled pulmonary cavity (A and B, red arrows) with an air-fluid level. A posterior chest tube is visible.

Five days before admission, enhanced CT was performed at another hospital.

What do you see?

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Findings: There are numerous pleural loculations containing air (A-C white arrows), compatible with the diagnosis of empyema. A thin-walled pulmonary cavity with an air-fluid level is visible (A and B, red arrows). There is also an endobronchial lesion in the RUL bronchus (C, yellow arrow) that was missed and not reported.

The patient was diagnosed of pneumonia with empyema. The symptoms improved after antibiotic treatment. Follow-up radiographs nine days after admission (below) showed that the RUL cavity had disappeared and the overall appearance of the right lung was better.

18 months later, the patient returned with cough, fever, and weight loss. Chest radiographs (below) were obtained.

What do you see?

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Findings: Radiographs show a peripheral rounded opacity (A and B, white arrows). In addition, there is an elongated opacity arising from the hilum in the lateral view, reminiscent of mucus impaction (B, red arrow).

Enhanced CT was performed. What do you see?

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Findings: Coronal and axial enhanced CT show an obvious mucus impaction in the RUL (A and C, white arrows) caused by the endobronchial lesion missed in the previous CT. The lesion can be seen protruding into the lumen of the intermediate bronchus (A, red arrow). A peripheral mass is also visible (B, yellow arrow).

PET-CT showed high uptake of the peripheral mass and the central lesion extending into the dilated bronchi (A-C, arrows).
Bronchoscopy confirmed a mass at the origin of the RUL bronchus. Biopsy identified squamous cell carcinoma.

This case concludes the trilogy on cavitary lesions associated with lung carcinoma (Diploma case 93 and Diploma case 118).

In this particular case, the patient had two different manifestations of carcinoma. Initially, the bronchial obstruction facilitated the development of an inflammatory cavity, which healed after treatment.

Later on, endobronchial growth of the tumor facilitated the development of a bronchial mucus impaction. It is important to remember that the most common cause of mucus impaction is malignant bronchial obstruction.


Follow Dr. Pepe’s advice:

1. Remember that cystic airspaces may be associated with carcinomas.

2. Carcinoma is the most common cause of mucus impaction.

3. Don’t forget to look at the bronchial tree in every CT scan!

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