Since this week is my birthday, I am showing a simple case. Chest radiographs were taken in a routine study for asbestos exposure in a 42-year-old man.
Will show more images on Wednesday.
showing today a cone down view of the lateral chest. What does the pattern suggest?
Click here to see the answer
Findings: PA radiograph shows punctate opacities in the upper and middle thirds of the right lung. The right heart border is indistinct (A, circle) suggesting RML disease.
The lateral view confirms RML disease (B, circle). A cone down view demonstrates thick lineal branching lines (C, circle) highly suspicious of dilated mucous-filled bronchi.
(Branching structures in chest radiograph are either vessels or mucous -filled bronchi).
Unenhanced sagittal and axial CTs show bronchiectasis of RML and lingula (D-E, circles).
Final diagnosis: RML bronchiectasis detected in the lateral view of the chest
Congratulations to MK, who made the diagnosis.
Teaching point: I presented this case because it is a nice example of bronchiectasis with mucous impaction suspected in the plain film. I posted it on Monday without having seen the CT because whoever read it told me that bronchiectasis were present.
I reviewed the CT two days ago and was surprised to discover two vital findings
that I had not been told:
1. The CT showed centrilobular and tree-in-bud opacities (F-G, circles), typical signs of bronchiolitis.
2. These findings plus RML and lingular bronchiectasis are a classic presentation of atypical mycobacterial infection.
So, what started as an unsuspected discovery in the plain film ended up with the serendipitous diagnosis of atypical mycobacterial infection (unproven, but likely). The attending physician has been notified and when a germ is found I would let you know