I am back with a new Diploma case. Miss Piggy sends her regards😍 and has helped to choose the case.
Chest radiographs belong to a 74-year-old man with a cough and pain in the chest.
What do you see?
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Findings: PA radiograph shows a bulge in the left paraspinal line (A, arrow), suggestive of a posterior mediastinal mass. A rounded posterior opacity is seen in the lateral view (B, arrow).
Unenhanced coronal and sagittal CT show large osteophytes displacing the paraspinal line (C, circle) pushing the aorta forward in the sagittal view(D, circle). Incidental gas is visible in the intervertebral disk.
Final diagnosis: large osteophytes simulating a pulmonary/mediastinal mass
The aim of this Diploma is to discuss chest imaging in the elderly. As patients get older the appearance of their chest radiographs changes in comparison with young persons. I intend to discuss changes associated to aging as well as the most common pathologies in the old.
I have divided the presentation into three separate chapters:
1- Bony structures of the chest
2- Heart and mediastinum
3- Lungs and diaphragm
Today I will comment on the main manifestations of aging in the chest skeleton, discussing variations that may simulate disease, followed by the most common bone pathologies in the elderly.
NORMAL VARIANTS IN THE AGED
Degenerative changes are the hallmark of the aging skeleton.Vertebral osteophytes are common and large ones should not be confused with pulmonary nodules (Fig 1) or mediastinal masses (Fig 2), as shown in the initial case. The diagnosis is easily made with chest CT.
Calcification of the first costal cartilage may happen in the young but it is more common in the elderly. When asymmetrical, it may be confused with a pulmonary nodule (Fig 3). Exuberant cartilage calcification may simulate an upper lobe infiltrate (Fig 4).
Aging causes brittle bones and explains the increased incidence of costal fractures in the elderly. The callus of a healed fracture should not be confused with a pulmonary nodule (Fig. 6).
Resuscitation maneuvers, not uncommon in advanced age, may cause bilateral rib fractures, that should be recognized as such (fig 7).
The most common bone pathology in the elderly are fractures. Acute rib fractures are common, most of them secondary to falls (Fig 8). Detection is important because they cause respiratory impairment that may end in pneumonia with the subsequent increase of morbidity and mortality.
Compression fractures of vertebral bodies are related to osteoporosis and common in the elderly. They cause significant pain, leading to inability to perform daily activities. If they are not recognized they cause a decline of the quality of life in elderly patients (Fig 9).
Lytic bone lesions in the elderly are usually related to metastases or multiple myeloma. Sclerotic metastases are common in old males. Given the prevalence of prostate carcinoma this should be our first diagnostic consideration in widespread sclerotic lesions (Fig 10). The differential diagnosis includes myelofibrosis (fig 11) and chronic renal failure (Fig 12).
Myelofibrosis is a myeloproliferative neoplasm which cause osteosclerosis. The association of an enlarged spleen should alert us to this possible diagnosis.
Solitary sclerotic lesions of the skeleton raises the possibility of metastasis vs. Paget disease. In the spine, Paget disease usually increases the size of the vertebra whereas metastases do not (Fig 13). In the peripheral skeleton the increase in width of the cortical bone is characteristic of Paget disease (Figs 14-15) .
Follow Dr. Pepe’s advice:
1. Osteophytes and healed rib fractures may simulate pulmonary nodules in the elderly
2. It is important to detect rib or vertebral fractures in the elderly because they may be the source of complications
3. Sclerotic bone lesions in the elderly are usually due to prostate metastases or Paget disease
17 thoughts on “Dr. Pepe’s Diploma Casebook 163 – SOLVED”
In right hemithorax both costodiaphragmal and cardiodiaphragmal sinuses are obscured with thickened pleura on anterior thorax wall and small gas-fluid levels projecting on costodiaphragmal sinus on PA and anteriorly at the level of diaphragmal contour.
Some air is seen in soft tissue – emphysema.
On lateral view at the level of lower lobe not homogeneous opacity is seen – could be shadow summation due to vessels, interstitial lung changes and osteophytes of thorax vertebrae.
Right insular hydropneumothorax with soft tissue (muscle) emphysema possibly iatrogenic.
There is also cardiac hypetrophy (both ventricles) – thus hydrothorax could be cardiogenic.
Elderly persons have multiple changes in the chest, most of them related to old age and without clinical relevance.
In my opinion, the most important finding is the lower lobe opacity in the lateral view.
….carissimo PROF….opacita’ omogenea in sede paramediastinica dx, con lieve sollevamento del diaframma ed iperchiarezza del restante polmone da atelettasia marcata del lobo medio ed inferiore….
There is an obliteration of the right costophric angle and seems to condition retraction of the hilum and neighboring structures. Prominente vascular bilateral hilum. In the lateral view there is an increased density in the inferior lobe.
Prominente aortic arc that displaces the trachea.
There is a calcificacion of the anterior longitudinal ligament (any relevant medical history?).
Center in the increased opacity of the lower lobe. Look for it in the PA.
The calcification of the ligament is probably a manifestation of DISH, which is not uncommon in the elderly
I think it is on the left retrocardiac area, next to the spine area
So, what do think?
Syndesmophyte that simulates lung injury?
So, what do you think?
Right costophrenic angle blunting
Epicardial fat causing obscuration of right cardiophrenic angle
Retrocardiac irregular opacity seen on lateral view in prevertebral region in lower zone
Spine appears kyphotic and osteopenia with marginal syndesmophytes
Bilateral paravertebral stripe widened inferiorly on PA view but no corresponding correlate on lateral view
Imp- ankylosing spondylitis with left lower lobe fibrotic changes and right costophrenic pleural thickening
See reply to MK, above
Good evening professor
1. Left lower zone non-homogenous opacity – likely consolidation secondary to infection.
2. Right lower lobe collapse.
3. Neck – Goiter.
I suppose it could neurogenic tumor – on lateral view the contour is slightly visible, still it is round
Pa reveals a focal lateral bulge of left paravertebral stripe. On lateral view , iregular ipacity in the left lower lobe. My opinion: suspect posterior mediastinal leasion – mass.
I am writing this commentary on Friday and all of you know the answer. Congratulations to MK, who made the diagnosis.