Dr. Pepe’s Summer cases: CASE 2 – SOLVED!

Dear Friends,

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.

Dear Friends,

presenting new images of the case. What do you think?

Click here to see new images

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.

14 thoughts on “Dr. Pepe’s Summer cases: CASE 2 – SOLVED!

  1. Hello!!!
    There is a pleural thickening in the upper right lobe. Next to it there is an increased density area with bad defined margins. Fractures on the 4 and 5 costal arc. Traumatic previous history?

  2. On PA CXR:-
    There is hyperinflation of both lungs with flattening of diaphragm suggestive of emphysema.
    There is well defined soft tissue density subpleural mass in upper lobe. It could be benign mesothelioma.
    On Lateral CXR:-
    Tenting of diaphragm
    Elongated retrosternal space.

  3. Right 4th and 5th rib fractures are seen with adjacent pleural thickening. There is also an hazy margin pleural based soft tissue mass in the same area (located hemothorax or pleural mass should be considered). CT is advised for further investigation.
    Normal heart and mediastinum.
    Costophrenic angles are clear.

  4. Lobulated pleural based opacification seen in right upper lobe.
    Rest of the lung field appear normal
    Differentials include loculated effusion, pleural lipoma or fibroma or other possibility is of pleural mets.
    CECT chest would be helpful

  5. Lobulated pleural based soft tissue density area in right upper lobe could be loculated effusion or pleural mass like fibroma, lipoma or pleural mets

  6. Your comments are correct, but you all are overlooking an additional finding. Remember satisfaction of search!

  7. Pleural based soft tissue opacity seen in RT upper lung zone with related rib fractures. Possibility of mesothelioma or meastatic pleural lesion should be considered

  8. Soft tissue mass involving the costal arc with pathologic fractures and subpleural extension. In the x-ray the hilum are prominent so adenopathy will probably be there (in CT there is a right paratracheal adenopathy).

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