Dear Friends,
Today I am showing the PA radiograph of an 82-year-old woman. Preoperatory for cataracts.
What do you think about the right hilum?
1. Calcified TB nodes
2. Sarcoidosis
3. Amyloid
4. None of the above
More images will be shown on Wednesday.
Click here to see the images shown on Monday
Dear friends, showing today PA and lateral radiographs taken two years earlier. Hope they help.
Click here to see the new images
Click here to see the answer
Findings: Initial PA radiograph shows opacities in the right hilum (A, circle), unchanged in comparison with a previous film taken two years earlier (B, circle).
The clue to the diagnosis lies in the density and appearance of the opacities. They are denser than the typical lymph node calcifications, suggesting that they are metallic. In addition, some of them look tubular or branching (C, red arrows). A lateral view taken two years earlier confirms dense lineal and branching opacities in right lung (D, arrows).
The combination of linear and branching metallic opacities suggests that they are either in the bronchi (previous bronchography) or within the pulmonary vessels (embolism after vertebroplasty o treatment of AV malformation). See Diploma # 44.
Lateral view of the lumbar spine shows surgical changes with vertebroplasty of L3 to L5 and leakage of the cement into the epidural veins (E, arrows), better seen in the sagittal CT (F, arrows).
Unenhanced CT confirms multiple cement emboli in the pulmonary arteries (G-J, circles)
Final diagnosis: cement embolization of the lung after vertebroplasty
I must mention Olena and Ayudi who suggested amyloid and broncholithiasis but failed to notice the metallic opacity of the findings.
Teaching point: Consider previous vertebroplasty when you see metallic opacities in the lungs. It is a common complication.
Unilateral right sided calcified lymph nodes- possibly calcified tb nodes
There are calcifications in the right hilum (DD tbc, occupational disease etc)
Interesting is on the left side the tube-like hyperlucency seen from the level of right hilum as far as diaphragm.
Need lateral view + clinical history
I believe the tubular hyperlucency is a false image created by the wall of the descending aorta and the LLL vessels.
More images on Wednesday
Sorry – mistake:
*from the level of left lung hilum
There’s tubular opacities in the lower area of both lungs, which are directing to the right atrium area; there’s one more subtle similar opacity above the right hilum – bronchial tree Amyloid deposition?
Also the calcification’s shape in the right hilum are not typical for lymph nodes; I assume they are in the vessels.
Good approach. Keep thinking 🙂
…doppio contorno sull’arco aortico, a sx, con calcificazione medializzata….ematoma intramurale….per le calcificazioni ilari è necessaria l’anamnesi….saluti PROF….
These tubular opacities (Ayudi) on both sides in lower parts are just calcified rib cartilages – which is normally for old patients.
Both new and previous chest PA x-rays seem to look the same – no notable changes.
Broncholithiasis?