Cáceres Corner Case 229 – Vignette

Hello friends,

After three weeks of confinement I believe I have seen all TV series available. If you like Sci-Fi I recommend The Expanse (Amazon Video) and for older citizens The Kominsky method(Netflix).

Today’s case was sent to me from my hospital in the early days of lockdown. The scout film belongs to a 78-year-old man with doubtful COVID-19 infection.
Do you see any abnormality?
If so, where is it?

1. Chest
2. Abdomen
3. Chest and abdomen
4. Don’t see it

Click here to see the answer

Findings: There is a rounded right mediastinal opacity at the junction of the trachea and right main bronchus (A, arrow). There is an apparent abdominal RUQ mass (A, red arrows) with an area of lesser opacity in the center (A, yellow arrow).
The correct answer would be number 3. Visible abnormalities in chest and abdomen

With these findings what would be your diagnosis?

1. Enlarged azygos arch
2. Azygos continuation of IVC
3. Right-sided stomach
4. All of the above

Click here to see the answer

The clue to the diagnosis resides in the apparent RUQ abdominal mass. The shape suggests a right-side stomach, with air in the antrum and duodenal bulb and lesser amount of air in the fornix (Fig A). Findings are better seen in the drawing (B).

A right-sided stomach with a normal-positioned heart is highly suggestive of a congenital abnormality, levocardia with abdominal situs inversus. In this malformation the chest structures are in their normal location, whereas the abdominal viscera are rotated 180 degrees.
This malformation is accompanied by partial interruption of the IVC and azygos continuation, which results in an enlarged azygos arch.
Therefore the correct answer is 4. All of the above

Click here to see the more images

Enhanced axial CT confirms the enlarged azygos arch (A, arrow). Coronal reconstruction demonstrates the dilated ascending azygos vein (B, arrows)

Axial images of the upper abdomen show the gastric fornix in the RUQ (C-D, arrows) as well as a normal left-sided heart (C) and a mid-line liver (D). There is a small splenic remnant in the RUQ (D, red arrow).

Final diagnosis: Levocardia with abdominal situs inversus

I am showing this case because this is our fourth patient with levocardia and abdominal situs inversus seen in the last four years (see Caceres´ corner cases 178 & 194 and Dr. Pepe´s Summer case 1). It may not be as rare as the textbooks state. In addition, the diagnosis can be suggested in the plain film if we discover the right-sided stomach.

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