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!