Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.
What do you see?
More images will be shown on Wednesday.
showing today chest radiographs taken one year earlier.
Do they help?
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Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).
Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).
The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.
CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).
Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).
The patient was found to have a history of asbestos exposure.
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.
Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!
12 thoughts on “Cáceres’ Corner Case 205”
Pleural based right upper lobe soft tissue mass
There is an opacity in the right apex medially. The lateral demonstrates that the anterior clear space is opacified. I favour this to be a subtle anterior mediastinal mass. Thank you.
Does it look like mediastinal in the PA view?
Right upper para tracheal vertically oriented opacity caused widening upper mediastinum
Slightly elevated right hilum
Raising possibility of anterior mediastinal mass or extremly collapsed RUL for CT study
There is a slightly displacement of the distal portion of the trachea to the right side. In the lateral view there is a high density in the retrosternal space, so I think in anterior mediastinal lesion.
Retrocardiac opacity in Pa view?
Double left para-aortic contour less visible one year later…?
Too many ideas…. SOS!!!
Dense areas on the left diaphragmatic and paracostal pleura suggestive of pleural plaques due to asbestos exposure. There is a right upper medial zone opacity, trachea is slightly displaced, retrosternal space more opaque than usual.
CT needed to evaluate for possible mediastinal lesion and signs of asbestosis.
calcified Pleural plaques seen on left side including costal and diaphragmatic pleura.
involvement of diaphragmatic pleura is suspicious for previous asbestos exposure.
Interval stability of findings seen, confirming chronic nature of thickening. further evaluation can be done by HRCT for asbestosis(early UIP pattern of ILD ).
I tinking that up Th vertebra are higher desity than others , year ago Was similar
PA view : Left basal linear atelectasis.
Lateral : Thoracic vertebra end plate irregularity