Showing today radiographs of a 27-year-old man with fever and hemoptysis.
More images will be shown on Wednesday
What do you see?
Dear friends, attaching CT images of the chest and abdomen. Do they help?
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.