Dear Friends,
Today’s case has been provided by my good friend and former resident Victor Pineda. Radiographs belong to a 56-year-old man with cough and fever.
What do you see?
More images will be shown on Wednesday!
Click here to see the images shown on Monday
Dear friends hope these new images help you with the diagnosis.
Click here to see more images
Click here to see the answer
Findings: PA chest radiograph shows a large paramediastinal lung opacity (A, arrow) that at first glance suggest malignancy. The clue to the diagnosis lies in identifying multiple bronchiectasis in the right and left central lung fields (A, circles).
The lateral view confirms the opacity in the posterior segment of the RUL (B, arrow) and bronchiectasis in the anterior clear space (B, circle).
Central bronchiectasis accompanied by lung opacities are typical of diseases with thick tenacious mucus and are the hallmark of cystic fibrosis o allergic bronchopulmonary aspergillosis. Coronal and axial CT confirm the presence of numerous central bronchiectasis, one of them with a large mucous impaction (C and D, arrows).
In the mediastinal window the impacted mucus is increased in density (E and F, arrows), which is a pathognomonic sign of ABPA.
Final diagnosis: ABPA with central bronchiectasis and dense pulmonary impaction
Congratulations to MG who was the first to answer and made a valiant effort to diagnose a difficult case.
Teaching point: this case looks difficult, but the diagnosis is easy if we identify basic findings. Discovering central bronchiectasis narrows the diagnosis to two entities and CT confirms one of them.
Good evening Professor,
There is a partially irregular opacity in the upper and medium part of the right lung. Opacity extends from the projection of the right hilium. On the lateral view it is located in the upper lobe, especially dense in its posterior part.
The projection of trachea is shifted to the right due to the lose of volume in the upper lobe.
Combined with fever and cough it suggests inflammation with constriction of bronchus. Bronchial carcinoma can’t be ruled out.
Brave answer and the only one! All of your colleagues have chickened out
1. CHEST PA –
– There is radioopaque mass lesion in the right paratracheal region causing mild deviation of the trachea to left side – origin from the lung – Malignancy.
– Prominent right hila – due to lymphadenopathy.
-Pulled up right hila – due to fibrosis.
2. LATERAL VIEW –
– There is underlying consolidation in the right lower lobe
Consolidation in the right upper lobe, with mediastinum ipsilateral deviation. Bronchiectasis, volume loss and scarring in the upper lobes, with predilection for the right side. Small centrilobular nodules in right lung. Right upper lobe cavitation.
These findings can be related to pulmonary Mycobacterium avium complex (or non tuberculous mycobacterial) infection.
Good morning Professor
Right hilar cavitating lung lesion surrounding emphysematous changes
1. Lung malignancy with necrotic cavitating lymph nodes
2. Systemic cavitating lung disease – granulomatous disease (Wegeners)
Good try! After reading the answer on Friday you will learn something new.
Consolidation in the right upper lobe, with mediastinum ipsilateral deviation. Bronchiectasis, volume loss and scarring in the upper lobes, with predilection for the right side. Small centrilobular nodules in right lung. Right upper lobe cavitation.
These findings can be related to pulmonary Mycobacterium avium complex (or non tuberculous mycobacterial) infection.
Allergic bronchopulmonary aspergillosis
Central and upper bronchiectasis
Hyperdense mucoid impaction
Right side consolidation
Very good. Sorry I cannot acknowledge your diagnosis in the answer because I sent it yesterday to be published today.
Hereby you are named official winner. Congratulations!