Cáceres’ Corner Case 252 – SOLVED

Dear Friends,

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.

Click here to see the images shown on Monday

Dear Friends,

showing today a cone down view of the lateral chest. What does the pattern suggest?

Click here to see the new images

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

9 thoughts on “Cáceres’ Corner Case 252 – SOLVED

  1. There are interstitial changes of both lung parenchyma as well as small random nodular opacities better seen on the left at the level of Vth rib (anterior part) and in RUL.
    There are also single small calcifications (on the right: VIth anterior rib, lower part of hilum. On the left: anterior part IIId rib middle clavicular line, in the left hilum).
    Right hilum has not its common normal structure – is deformed and shifted slightly upwards.
    On lateral view: fibrous changes (fibrous atelectasis) of the right middle lobe.

  2. CXR PA, and lateral,
    Biteral fine reticular opacity with small nodular perihilar opacities
    Loss of right heart border (silhouette sign)indicative of middle lobe pathology ,with corresponding fibrotic changes Rt middle lobe in the lateral view most likely fibrosis
    No loss of lung volume despite obvious fibrotic changes Right middle lobe
    Mild ground glass opacity right upper lobe

  3. Good morning and Happy birthday for your 25 years old!!!!!!!!!!!!!!!

    There are bilateral intersticial changes and I think that there are bronchiectasis on the middle lobe probably in relation with abestos exposure changes.

  4. On cone down view:
    There is increased transparency of the lung parenchyma near anterior chest wall reminds bullous changes (if this is the case of fibrotic changes of RML).
    But it also looks like the beginning of lung intercostal herniation at two intercostal levels.
    Was any trauma in anamnesis?

  5. Well, due to exposure of asbestosis fibers, lung fibrosis is most common suggestion.
    But now, thanks to Your question, I go back to that changes I have cut off as unreliable.
    Asbestosis exposure has also its worse prognosis – malignancy.
    On lateral view I thought at the beginning that there is some irregular mass opposite and very close to the left atrium as well as second similar above at the level of ascending aorta, but have thought this is imagination and just lung vessels.
    Doubtful also looks the area paravertebrally near the middle of right atrium projection on PA.
    Right heart border line is absent.
    Going back to Your opinion what You see, it reminds me only pathological process of any of bronchovascular and secondary pulmonary lobe structures) – lung edema, lymphoproliferation, both – which commonly should not be localized only on one side and limited with one lobe.
    So, except lung ca, as possible, have no other ideas.

    I also wish You happy birthday! Hope, the cake was delicious!

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