Cáceres’ Corner Case 254 – SOLVED

Dear Friends,

today’s radiographs belong to a 34-year-old woman with moderate cough. Previous history of asthma.

What do you see?

Diagnosis:

1. Mucous plug
2. Segmental atelectasis
3. Tuberculosis
4. None of the above

Click here to see the answer

Findings: Pa chest radiograph shows a tubular opacity that seems to arise from the right hilum (A, arrow). The lateral chest (B) does not show any abnormality, which raises the possibility that the opacity in the PA view is spurious.

Careful inspection demonstrates that the opacity extends to the right apex and to the neck (C, red arrows). The appearance is typical of a superimposed pigtail.

Some of you described the slightly elevated minor fissure. It is an unfortunate coincidence, probably related to previous episodes of mucous plug in an asthmatic patient causing mild loss of volume of RUL.
 
Final diagnosis: Pigtail simulating pulmonary disease.
 
Congratulations to MK who was the only one to suggest the correct diagnosis.
 
Teaching point: You may think that I tricked you, but it was not my intention. This case is a reminder that apparent pulmonary opacities may be located in the pleura, chest wall or outside of the body.
 
To emphasize this point I am showing two more cases of braids simulating pulmonary disease, presented in earlier blogs.

CASE 1. 48-year-old woman with mild cough. PA radiograph shows an ill-defined opacity in the left lung, running from top to bottom (A, white arrows). The opacity extends towards the neck (A, red arrow), which suggests that it is external to the lung. Lateral view shows an elongated opacity in the back of the chest (B, arrows).

A photo of the patient (C) confirms that a long braid is the cause of the opacity. PA radiograph after lifting the braid demonstrates that the chest is normal (D).

CASE 2. 25-year-old man with braided hair simulating a RUL infiltrate (A, arrow). The opacity extends to the neck, giving away the diagnosis (A, red arrow). After raising the braid, the chest looks normal (B). Remember that men also wear their hair long nowadays.

15 thoughts on “Cáceres’ Corner Case 254 – SOLVED

  1. none of the above? The right apex and right upper zone vasculature appear to be abnormal (to my musculoskeletal radiologist eyes). I could be totally off though… Looking forward to seeing her CT images!

  2. There is upward displacement of minor fissure of right lung with increase bronchi-vascular marking in upper lobe,and patchy opacity in right apex,I would go with atlectasis ,and aspergilosis should be considered as underlying cause

  3. Good morning!!

    Leptosomic habit, with pseudonodular incureased density in right apical region (on the left side it is no so relevant) that extend to the hilum, but I think she could have a pony tail or hair braid…

  4. More for 4. though there are some fine subpleural apical changes in RUL (more laterally) as well as though the fissure is seen on its usual level (III anterior rib) but it is saddle-backed-like upwards, thus I suppose RUL is decresed in size (post tbc changes?).

    It is quiet complicated to follow the airways (trachea and bronchi), more on the right; there is long tube-like hyperlucency (along the heart on the right)

    On lateral view the “hilums” structures have not the common anatomy appearance as well as both lung fields are poorly vascularized (more than 2 cm I suppose on lung periphery) – vessel congenital disorder (lung arteries hypoplasia?)

  5. P.S. Dropped in eye horn like changes on the right of the margins of two vertebral bodies between 9-10 ribs – osteophyte? (the patient is too young for this – if there are degenerative changes at all)

  6. Chest radiography PA and lateral show signs of segmental atelectasis with upwards displacement of the horizontal fissure and pulling up of the right hilum.Can be secondary to chronic inflammatory pathology.

  7. Both lungs are hyper-inflated . There is a round structure at left hilar level that could be dilated bronchus with inspissated mucus or cavity with aspergillosis.

  8. CXR PA view shows a rather band like opacity extending from superior border of right hilum upwards to right paratracheal region and then goes upwards to the neck . There is a thin pulmonary stripe which is mimicking upwards displacement of transverse fissure but then upwards displacement of transverse fissure not appreciated on rt lateral view
    On Rt lateral view there is an end on opacity anterior to the trachea superior to the right hilum which is leading to a triangular opacity which faints upwards.
    Dx- Possibly a hair braid artifact . ( opacity extending upwards to neck) . Imp action of such a central bronchi would not lead to such a small segmental collapse .

  9. CXR PA view shows a rather band like opacity extending from superior border of right hilum upwards to right paratracheal region and then goes upwards to the neck . There is a thin pulmonary stripe which is mimicking upwards displacement of transverse fissure but then upwards displacement of transverse fissure not appreciated on rt lateral view
    On Rt lateral view there is an end on opacity anterior to the trachea superior to the right hilum which is leading to a triangular opacity which faints upwards.
    Dx- Possibly artifact . ( opacity extending upwards to neck) . Imp action of such a central bronchi would not lead to such a small segmental collapse .

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