Dr. Pepe Case 140 – Art of interpretation – SOLVED!

Dear Friends,

I am presenting today a new “Art of interpretation” case.
Radiographs belong to a 51-year-old with chest pain, dyspnea and D-dimer of 750.

Diagnosis:
1. Pulmonary infarct
2. Pneumonia
3. Chronic pulmonary changes
4. None of the above

What do you see? Come back on Friday to see the answer!

Click here to see the images


Click here to see the answer

Findings: the PA radiograph shows an ill-defined opacity in the right mid-lung field (A, white arrows) which looks intrapulmonary. There is blunting of the right costophrenic angle, indicative of pleural disease (A, red arrow).

The main diagnostic findings are seen in the lateral view. There are oblique posterior pulmonary strands (“crow’s feet”) (B, white arrow) which lead our attention to a posterior vertical white line (B, red arrows), which represents calcified pleura.
A negative finding is the absence of pulmonary disease in the lateral view.

These findings are better seen in the cone down views (C and D, arrows) .

Analysis of findings:
1. Apparent pulmonary disease in the PA radiograph
2. No visible pulmonary disease in the lateral view
3. Blunting of costophrenic angle with calcified posterior pleura
4. Crow’s feet

Summing up the findings: The apparent pulmonary disease in the PA view, which was not seen in the lateral view, together with chronic pleural disease (evidenced by blunting of the costophrenic angle and calcified posterior pleura) are highly suggestive of pleural disease simulating a pulmonary infiltrate.

APPARENT PULMONARY DISEASE IN THE PA RADIOGRAPH, NOT SEEN IN THE LATERAL VIEW + CALCIFIED PLEURA IN THE LATERAL VIEW = CALCIFIED PLEURA SIMULATING PULMONARY DISEASE.

Enhanced axial CT confirms the posterior calcified pleura (A, arrow), the lack of pulmonary infiltrate, and the crow’s feet adjacent to the diseased pleura (B, red arrow).
Crow’s feet are better seen in the coronal and sagittal reconstructions (C and D, red arrows), especially the sagittal view, which is practically identical to the lateral chest radiograph.

Final diagnosis: Pleural calcification simulating pulmonary infiltrate

(My heartfelt thanks to Dr. Eva Castañer for providing the CT images)

Pleural calcifications are not uncommon. Bilateral calcifications are almost always related to asbestos exposure. Unilateral calcifications are usually due to a previous infection or hemorrhage. In any case, when located in the anterior or posterior chest wall they are seen en face in the PA radiograph and may be confused with pulmonary infiltrates, as in the present case. Seen in profile in the lateral view they appear as a calcified line, and the diagnosis is then evident.

Sometimes, the calcified pleura are overlooked. In this particular case we have a useful marker that points our attention to the diseased pleura: the radiologic sign known as crow’s feet which represents subsegmental areas of peripheral fibrosis/atelectasis fixed by the fibrotic pleura. They are likely an early stage of rounded atelectasis. (Personally, I prefer the alternative term sun rays rather than crow’s feet. As a frequent visitor to Minorca, I am more familiar with sun rays than with crows, let alone their feet).

To emphasize the deceitful appearance of pleural calcification, I am showing two more cases.

FIRST CASE

Radiographs belong to a 52-year-old asymptomatic woman. The PA radiograph shows what appears to be a poorly-defined pulmonary infiltrate in the left lung (A, arrow). The lateral view shows two calcified pleural plaques: the posterior one is depicted as a calcified line (B, white arrow), whereas the anterior one is more oblique and simulates a rounded opacity (B, red arrow).

Sagittal CT clearly shows the anterior (C, arrow) and posterior plaques (D, arrow). No pulmonary infiltrates were seen in the lung view (not shown).

SECOND CASE

Preoperative PA chest radiograph in a 57-year-old man. There are several opacities in the left hemithorax that may be pulmonary infiltrates (A, white arrows) accompanied by left diaphragmatic and pleural calcifications (A, red arrows).

In the coronal CT (B) there are no lung abnormalities. Enhanced axial and sagittal CTs depict extensive pleural calcification (C and D, arrows). The apparent pulmonary infiltrates were due to pleural calcifications depicted en face. The patient had a history of TB in his youth.


Dr. Pepe’s teaching points:

1. Pleural disease can simulate pulmonary infiltrates.

2. Crow’s feet can direct our attention to overlooked pleural disease

Cáceres’ Corner Case 203 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today enhanced CT images of the case.

Do they help?

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.

Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
 
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
 
Congratulations to MK, who was the first to suggest the correct diagnosis.
 
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).

Dr. Pepe Case 139 – Webinar

Dear Friends,

Presenting PA chest radiograph of a 57-year-old woman with dyspnea and  fever.

What would be your diagnosis?
1. Lobar collapse
2. Pneumonia
3. Unilateral pulmonary edema
4. Any of the above

You have one week to post your answers. The correct answer will be given during the webinar of Wednesday 3 at 12:30 P.M.
You can join the webinar here

Click here to see the image

Cáceres’ Corner Case 202 – SOLVED!

Dear Friends,

Dr. Pepe is busy preparing next week’s webinar (click here to register!) and asked me to present a case this week. The case is provided by my friend Jordi Andreu.

Radiograph belong to  a 83-year-old woman with dementia. A mass was detected in the right lung and a CT was done.

What do you think?

Click here to see the images

Click here to see the answer

Findings: AP chest radiograph shows a well-defined opacity in the right upper hemithorax (A, arrow) which appears to be extrapulmonary. There are calcified granulomas in the left apex with retraction of the left hilum.

Unenhanced axial and coronal CT show an extrapulmonary mass with a calcified rim (B-C, arrows). The mass has a striated appearance, alternating lineal areas of different opacities. This CT appearance is practically pathognomonic of oleothorax (see case 19 of Caceres’ corner).

Instillation of oil in the extrapleural space (oleothorax, plombage) was used to collapse the lungs facilitating healing of TB cavities. It was abandoned in the early fifties after the discovery of effective antimicrobial therapy.
The patient had pulmonary TB in her youth and told us that it was treated by instillation of a substance. A clinical photograph in another patient (D) documents the surgical scar.

Final diagnosis: Oleothorax
 
Congratulations to Diogo, who was the first to make the diagnosis and to Jake, who concurred two days later.
 
Teaching point: this is an uncommon pathology, but it should be known because the appearance is pathognomonic and shouldn´t be confused with other conditions. This patient was seen four weeks ago and diagnosed initially of pleural tumour.

Cáceres’ Corner Case 201 – SOLVED!

Dear Friends,

my good friend José Luis López Moreno gave me this case: preoperative chest radiographs for hand surgery in a 39-year-old woman.

What do you see?

Com back on Friday to see the answer!

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a rounded opacity in the periphery of the left lung
(A, arrow) that seems to be calcified. Cone down view shows a whorled pattern (B, arrow). A braid is visible in the left supraclavicular area (A, red arrow). Lateral view (not shown) is unremarkable.

Scout view of the CT does not show the apparent lung lesion, which is not visible in the axial view of the lung (D).
The technician that took the chest radiograph told us that the patient had a long braid with a rubber at the end.

Final diagnosis: hair braid simulating a lung nodule
 
Congratulations to MK who was the first to suggest the right diagnosis. Kudos for effort to Coffee.
 
I must confess that I was fooled when showed this case. Despite noticing the braid in the left supraclavicular area (A, red arrow) I failed to connect it to the apparent lung nodule. I suspected a skin artifact, without excluding an osteochondroma of rib or scapula.
 
Teaching point: after showing three braid artifacts in the blog (case 109, 172 and 191), I missed the fourth one.
Nobody is perfect!

Dr. Pepe’s Diploma Casebook: CASE 138 – MEET THE EXAMINER

Dear Friends,

in the aftermath of the European Congress of Radiology a have elected to show a new “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer.

This case starts with a preoperative PA chest radiograph of a 52-year-old man. No other information was provided in the request. What do you see?

Click here to see the answer

Findings: PA radiograph shows an obvious convexity of the left paraspinal line (arrow). There is an abnormal opacity in the periphery of the right lung (circle), which may be related to the rib cage.

Click here to obtain more information

After seeing the chest radiograph, we looked into the case further and discovered that the patient was scheduled for biopsy of a collapsed mid-thoracic vertebra, which would explain the bulging of the paraspinal line. Below is the MRI study. What would be your diagnosis?
1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

Click here to see the answer

Findings: The eighth thoracic vertebra is flattened, impinging on the spinal canal. There is a central lesion in D7 and a smaller one in the anterior aspect of D5. (arrows). The findings were interpreted as an aggressive hemangioma at D8 and smaller hemangiomas at C7 and C5. A CT was requested to obtain more information.

Click here to see the CT

Axial, coronal and sagittal CT images are shown. What would be your diagnosis?

1. Aggressive hemangioma
2. Metastases
3. Myeloma
4. Any of the above

Click here to see the answer

Findings: axial CT (A) shows the typical “polka dot” appearance of vertebral hemangioma.
Coronal and sagittal views demonstrate the collapsed vertebra (B and C, white arrows) with a soft-tissue mass (B, red arrow) which explains the finding in the chest radiograph. A punched-out cortical lesion in D5 was overlooked (C, yellow arrow).

Click here to see more studies

In the meantime, we were concerned about the abnormal right peripheral opacity seen in the chest radiograph. Oblique views of the right hemithorax were taken. What do you see?

Click here to see the answer

Findings: the right oblique view shows what appears to be an old rib fracture accompanied by pleural thickening (A, white arrow). A serendipitous finding is the discovery of lytic lesions in the scapula (A, red arrows). The left oblique view also shows a lytic lesion in the right humerus (B, arrow).

The findings in the oblique chest radiographs prompted a review of the spinal CT. Numerous punched-out cortical lesions that had been overlooked were noted (arrows). This discovery suggested widespread malignant bone infiltration. Given that the patient was in good general condition, multiple myeloma was the first diagnostic choice. Vertebral biopsy provided the final diagnosis of myeloma.

Final diagnosis: multiple myeloma invading a vertebral hemangioma

Vertebral hemangioma is the most common vascular lesion of the spine and is present in about 10% of the population. The favored location is the mid-thoracic spine. In this particular patient we suspect that an unrelated multiple myeloma had invaded a previous vertebral hemangioma, causing collapse of the vertebral body. This responds to the concept of locus minoris resistentia, in this context referring to organs or regions that for some reason are more vulnerable than others. In this case, the wide vascular spaces and increased blood supply of the hemangioma may have facilitated implantation of malignant cells.

The typical appearance of coarse trabeculae (polka dot) of the original hemangioma, plus satisfaction of search were the reasons for the initial misdiagnosis of invasive hemangioma. The findings in the plain films of the chest were decisive to reconsider the diagnosis, leading to a review of the cross-sectional studies and the correct diagnosis.


Follow Dr. Pepe’s advice:

1. Remember Dr. Pepe’s words of wisdom (Diploma case 132): Don’t let one abnormal finding keep you from looking for another

2. Sometimes, plain films have an important role in the diagnosis.

Cáceres’ Corner Case 200 – SOLVED!

Dear Friends,

the first case of Caceres’ corner was published in September 23, 2011. Today, seven years later, we are proud to present case 200. It was not always easy, but it was always fun and worth it. Thank you for your continuous support.

Today’s case was diagnosed by my friend and co-worker Carles Vilá. The PA radiograph was taken as a pre-op exam for renal stones.
Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images

Dear Friends,

we saw a peripheral opacity in the lower left hemithorax and performed a CT, which showed unexpected findings.
What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the periphery of the left lower hemithorax (A, circle). A CT was recommended.

Axial CT shows an unexpected irregular basal opacity (B, arrow). Caudal slices show several parietal nodules (C-D, arrows).

Coronal CT shows the large basal opacity (D, arrow), as well as the small parietal nodules (D-E, red arrows).

The clue to the diagnosis lies in a negative finding: absent spleen in the left upper quadrant of the abdomen (D-E, asterisks), suggesting that the chest opacities may represent accessory spleens.
The patient was interrogated and stated a previous car accident with ruptured spleen and subsequent splenectomy. A test with labelled erythrocytes in another institution confirmed the accessory spleens.
 
Final diagnosis: thoracic splenosis
 
As I am writing this (12:00 PM Thursday), nobody has suggested the right diagnosis. I was expecting many correct answers, since I showed a similar case eight weeks ago (Diploma case 135).
 
Teaching point: remember the importance of negative findings (Diploma cases 135 and 136). In this particular patient, they were crucial to suggest the correct diagnosis.

Congratulations to MK, who made a last-minute diagnosis at 2:08 P.M. on Thursday!