Dear Friends,
Today’s case has been provided by my good friend Victor Pineda. Radiographs belong to a 36-year-old man with cough and fever. For comparison, I am including radiographs taken nine years earlier.
Diagnosis:
1. Chronic TB changes
2. Endobronchial lesion
3. Congenital lesion
4. None of the above
What do you see? More images will be shown on Wednesday. Come back on Friday to see the answer.
Click here to see the images posted on Monday
Showing coronal and axial CT images. What do you think?
Click here to see the CT images
Click here to see the answer
Findings: Pa radiograph shows a left ill-defined opacity that blurs the upper mediastinal contour (A, arrow) and the lower cardiac border (A, red arrow). In the lateral view there is a retro-sternal line that goes from top to bottom (B, arrows). The appearance is typical of marked LUL collapse, which has not changed in the last nine years. Therefore, the most likely diagnosis is a benign condition that occludes the origin of the LUL bronchus.
Enhanced axial and coronal CTs show marked irregularity of the origin of the LUL bronchus (C, arrow) due to a large mass with coarse calcification (C-D, circles) causing distal lobar collapse. The most likely diagnosis is a benign tumor, either carcinoid or hamartoma. Given the size of the mass and the higher frequency of carcinoid, I would favor this diagnosis. It was proved by biopsy and surgery.
Final diagnosis: endobronchial carcinoid with LUL collapse
Congratulations to Ahmed Al Ani who was the first to suggest the correct diagnosis in the plain film.
Teaching point: Detecting LUL collapse in chest radiographs is important because the great majority are secondary to bronchogenic carcinoma. This patient was lucky.
Stationary lesion from 2011-2020 haziness overlying the left cardiac border including Aortic knuckle
There is abnormality seems to be along the left main bronchus ? Narrowing
Put endobrochial lesion as a DD
Correct. CT images tomorrow
Good morning!! Congenital lesion is a good dx!!
The x-ray is very similar to the x-ray 9 years before.
I can´t see the left vascular hilum. There is a subtle loss of volume of the left hemitorax and a central increased density. In the lateral view I can see a vertical retrosternal line that is typical of hypoplasia!!
Dx: Congenital vascular hypoplasia
Left perihilar opacity, justaphrenic peak and the major fissure are well seen on the lateral view and a they were already in 2011, a chronic atelectasis of the left upper lobe (or a congenital malformation as is saying Mk?).
Now there is an increased opacity in posterior left lower lobe
It call my attention the aortic knob is higher than usual.
Me faltó poner que la opacidad perihiliar y el pico yuxtafrénico es en el frente… Se entiende igual. Fue la culpa de mi inglés
No problemo. El mío es mucho peor!
4
LUL collapse, unchanged from previous radiograph. A benign endobronchial lesion (e.g. hamartoma), bronchial stenosis or foreign body would be in my differential list.
Well done! Although it would be unlikely for a foreign body to lodge in the LUL bronchus 🙂
Congenital lesion . Been stable for 9 years.
Not all stable lesions are congenital. See CT images tomorrow
Left upper lobe collapse – endobronchial lesion. Given the time frame… Carcinoid?
Bronhogenic chist !!!