Cáceres Corner Case 235 – Vignette

Dear Friends,

Recommendations for this week: two series, Goliath and Fleabag both of them in Amazon. 

Today’s radiographs belong to a 32-year-old man with persistent cough. Non-smoker.

Diagnosis:

1. Bronchogenic carcinoma
2. Benign endobronchial tumor
3. Endobronchial TB
4. Any of the above

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Findings: PA shows a triangular opacity in the right upper lung (A, arrow), suggestive of RUL collapse. The collapsed lobe abuts against the major fissure in the lateral view (B, arrow).
The findings point to an obstructive lesion at the origin of the RUL bronchus. I would say that the most likely diagnosis is carcinoma, despite the age of the patient, because it is a common lesion, but I could not discard the other options. A CT is indicated.

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Unenhanced CT was done. What would be your diagnosis?

1. Carcinoma
2. Benign endobronchial tumor
3. Tuberculosis
4. None of the above

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Findings: coronal reconstruction shows obstruction of the RUL (C, arrow). Unenhanced axial slice shows the collapsed lobe with rounded high-attenuation areas within it (D, circle).

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Coronal reconstruction shows high-attenuation branching structures within the collapsed lobe which represent mucous impaction (E, circle). Dense mucus at CT is very characteristic of allergic bronchopulmonary aspergillosis (ABPA), which is the most likely diagnosis.
ABPA is accompanied by chronic sinus disease and facial CT shows marked affectation of both maxillary sinuses (F).

Final diagnosis: RUL collapse secondary to mucous plugs in ABPA

After removal of the plugs by bronchoscopy, the chest shows marked improvement.

Allergic bronchopulmonary aspergillosis is caused by hypersensitivity reaction to Aspergillus organisms. Excessive mucus production and abnormal ciliary function lead to mucoid impaction.
Radiologic manifestations include finger-in-glove images in a bronchial distribution They are related to plugging by hyphal masses with distal mucoid impaction. Occasionally, isolated lobar or segmental atelectasis may occur.
In approximately 30% of patients, the impacted mucus has high attenuation at CT

N.B. For those of you who noticed the similarity with case 232 (azygos lobe pneumonia), I should point some subtle but important differences between both cases:

In case 232 the fissure is convex (unusual in collapse). In the present case is straight.
In case 232 the fissure ends before reaching the hilum. In the present case the fissure ends in the hilum.
In case 232 the hilum is of normal size and the RUL artery is visible (arrow). In the present case the hilum is smaller because the RUL artery is included in the collapse.


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