Cáceres’ Corner Case 251 – SOLVED

Dear Friends,

Showing today radiographs of a 27-year-old man with fever and hemoptysis.
More images will be shown on Wednesday

What do you see?

Click here to see Monday images


Dear friends, attaching CT images of the chest and abdomen. Do they help?

Click here to see more images

Click here to see the answer

Findings: chest radiographs show a cavitated pulmonary lesion in the apical-posterior segment of the LUL (A-B, arrows). There is convexity of the left middle mediastinum
(A, red arrow).

Enhanced axial CTs show an irregular pulmonary mass with cavitations (C-D, arrows). The thymus is enlarged, with a central area of decreased density (D, red arrow).

Enhanced axial abdominal CTs demonstrate enlarged retroperitoneal lymph nodes
(E-F, circles) as well as enlarged mesenteric lymph nodes (E, red ellipse).

In summary, the findings are:
 
Cavitated lung mass. Etiology: TB, fungal infection, lymphoma, Wegener and other granulomatosis.
Enlarged thymus. Etiology: thymoma, germ-cell tumor, thymic lymphoma
Enlarged retroperitoneal and mesenteric lymph nodes. In my opinion, this is a crucial finding, because it is highly suspicious of lymphoproliferative disease.
 
Putting all the findings together, lymphoma is the most likely diagnosis.
In this patient the initial diagnosis was TB. No TB germs were grown from the bronchial aspirate and PPD was negative. Abdominal CT seven days after admission suggested the diagnosis of lymphoma, confirmed by biopsy, which demonstrated widespread Hodgkin disease, nodular sclerosis type.
 
Final diagnosis: Cavitated Hodgkin disease of the lung.

Congratulations to all of you who made a gallant effort to diagnose the case. Will single out Olena because she was the first to mention lymphoma.
 
Teaching point: As this case proves, cavitated lesions of the lung are difficult to diagnose by chest imaging alone. Sometimes you need all the help you can get.

16 thoughts on “Cáceres’ Corner Case 251 – SOLVED

  1. There is a mass with central cavity seen in the app co posterior segment of the left upper lobe, a vascular core seen between the lesion and left hilum with enlarged hilar lymph nodes. Smaller nodules can be seen at both lungs as well.
    Ddx; infection in nature like active PTB. A mass with central breakdown.
    Other differentials could be possible like Vascular as Wagner granulomatosis.

  2. I partly agree with the description above – I would say infiltration with cavitation.
    in DDx I would add: (due to young age)
    – sarcoidosis (nodular variant, with cavitation)
    – lung lymphoma
    Without additional information (clinical,anamnesis/other imaging) DDx sound controversial.

  3. left upper lobe cavitary lesion(apico-posterior). As patient presented with fever (since when?) I would suggest infection
    Differential
    1-cavitary pneumonia (coused by virulence e,g organism staph,kelibsila)
    2-infected lung sequestration
    3-pulmonary TB
    Less likely Wagner granulomatosis, rapidly growing deposit
    Next step after correlation with clinical data, CT +\- contrast

      1. Thank you for your kind comment.
        Regarding CT Abdomen ,1-Rt renal pelvis is dilated (needs to check lower section for possible related obstructing mass),
        2-multiple para aortic lymph nodes seen(the left para aortic round structure similar to double inferior vena cava? More section required to check) ,nodular like structures in mesentery noted
        3-the spleen extended up to the lower third of left kidney,? Splenomegaly
        For me I still cannot reach the diagnosis
        But underlying malignancy is considered,vs connective tissue disorder
        Needs more section before and after contrast

  4. Chest x-ray reveal patchy opacity in left midzone with eccentric cavitation and extending to left hilum. On lateral chest x-ray, a tubular opacity is seen posterior and superior to hilum. Also left hilar shadow is enlarged. Another small rounded nodular shadow in left apical region.
    Differential diagnosis includes-
    1.consolidation with cavitation-Tuberculosis is a possibility.
    2.Fungal infection with mucoid impaction- ABPA/pulmonary aspergillosis
    3.Granulomatosis with polyangiitis, though, single cavitatory lesion is seen.

    Chest CT would next investigation of choice with clinical details.

  5. Good morning!

    There is a cavitated lesion in the upper left lobe with hiliar retraction and an obliteration of the aorto-pulmonary window (adenopathies). I think in TBC.

  6. There are retroperitoneal adenopathies with hyperdense center (probably calcified) and right pieli renal ectasia.

    Left pulmonary consolidation with central cavitation/bronchiectasia

    Anterior mediastinal lesion (probably tymic lesion).

    I think about Catleman disease…

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