Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?
More images will be shown on Wednesday.
showing today axial and coronal CT.
What do you think?
Click here to see the answer
Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.
Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).
In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).