As promised, I am presenting the second summer case. Radiographs belong to a 47-year-old man with low-grade fever and pain in the right hemithorax for the last two months.
What do you see?
More images will be shown on Wednesday.
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
presenting new images of the case. What do you think?
Click here for the answer
PA radiograph shows abnormalities of the 4th and 5th right ribs (A, red arrows), accompanied with an extrapulmonary mass. In addition, there is an obvious thickening of the right paratracheal line (A, white arrows), suspicious of mediastinal adenopathy. The lateral view is unremarkable.
Enhanced CT confirms the rib destruction and the extrapulmonary mass (C, circle). The axial view shows that the mass does not enhance, and is slightly less dense than the soft tissues (D, circle). PET-CT shows marked uptake of the mass and mediastinal lymph nodes (E, arrows).
In my humble opinion, the clue to the diagnosis lies in the oblique rib radiograph (F, circle). Whereas the lesion in the 5th rib seems aggressive, the one in the 4th rib looks more indolent, with a well-defined cavity in the medullary (G, white arrow). This appearance suggests (at least to me) a chronic granulomatous process rather than a malignant one. Stretching the point, I can even see a sequestrum in the 5th rib! (G, red arrow).
Tru-cut biopsy of the mass discovered Mycobacterium tuberculosis.
Final diagnosis: active TB of ribs and chest wall.
Congratulations to all of you who participated and fought against unsurmountable odds.
My heartfelt thanks to my good friend Eva Castañer, who provided the CT and PET-CT images.