Author: Dr. Pepe

Cáceres’ Corner Case 216 – SOLVED!

~ Dr. Pepe ~ 12 Comments

Dear Friends,

Today I am showing another case provided by my friend Dr. López Moreno. Radiographs belong to a 25-year-old woman with fainting spells. 

What do you see?

More images will be shown on Wednesday.

Dear Friends,

Showing coronal and sagittal images of enhanced CT.
What do you see?

Click here to see more images

Click here to see the answer

Findings: PA radiograph shows convexity of the aorto-pulmonary window (A, arrow) which is encroaching upon the left hilum. Aside from a discrete pectus excavatum, I don’t see any significant findings in the lateral view (B).

According to Diploma 144, the main causes of a prominent A-P window are either enlarged lymph nodes or an arterial aneurysm and a CT should be obtained. In this particular patient coronal enhanced CT shows an aortic aneurysm projecting over the A-P window (C, arrow) and located anterior to the aortic arch in the sagittal projection (D, arrow).

The appearance is compatible with traumatic pseudoaneurysm, but the patient did not have any antecedent of traumatism. In our opinion (Dr López Moreno and mine) we believe that it represents a ductus aneurysm because of the location and the thin band joining the aneurysm and the pulmonary artery (E, circle). The pinpoint calcification in the middle of the band may be calcium in the ductus ligament or be secondary to partial-volume effect.

An unexpected finding is the compression of the left main bronchus by the aneurysm (E-F, arrows). It would have been interesting to perform expiration films to detect air-trapping of the left lung.

Some of you have mentioned Kommerel diverticulum. This malformation is located posteriorly and occurs in aberrant subclavian artery, which courses behind the trachea and pushes it forward in the lateral chest radiograph. You can see examples in case 213 of Caceres’ corner and Diploma cases 2, 9 and 84.
 
Final diagnosis: Probable aneurysm of the ductus arteriosus
 
Congratulations to S who was the first to think of the ductus in the plain film and made the diagnosis of ductus diverticulum after CT.
 
Teaching point: this is my first ductus aneurysm (if we are right) and I cannot have much to say. Perhaps to stress again the importance of looking at the aorto-pulmonary window in the PA radiograph.

Dr. Pepe’s Diploma Casebook 150 – All you need to know to interpret a chest radiograph – Fourth Session

~ Dr. Pepe ~ 5 Comments

Dear Friends,

Presenting today the leading case of the next webinar. PA radiograph of a 58-year-old woman with cough and fever.

What do you see?

The answer will be published on Friday. While you wait, you can check the first three webinars, check the EBR youtube channel!

Click here to see the image

Click here to see the answer

Findings: PA chest radiograph shows an ill-defined opacity behind the right hemidiaphragm (A, red arrows), better seen in the cone-down view (B, red arrows). The fact that the opacity is visible indicates that it is surrounded by air, placing it in the right lower lobe.

A lateral view confirms air-space disease in the RLL (C, circle), blurring the posterior aspect of the right hemidiaphragm.

Final diagnosis: RLL pneumonia
 
Congratulations to archanareddyt who was the first to see the opacity and to MK who saw it and suggested the right diagnosis.
 
Teaching point: Remember that in the PA view the lower lobes go deep behind the diaphragm. Pulmonary disease of any kind can be seen in the upper quadrants of the abdomen, as demonstrated by the present case.

Remember to check the webinar published on the EBR youtube channel!

Cáceres’ Corner Case 215 – SOLVED

~ Dr. Pepe ~ 9 Comments

Dear Friends,

Today’s case has been provided by my good friend and former resident Victor Pineda. Radiographs belong to a 56-year-old man with cough and fever.
What do you see?

More images will be shown on Wednesday!

Click here to see the images shown on Monday

Dear friends hope these new images help you with the diagnosis.

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a large paramediastinal lung opacity (A, arrow) that at first glance suggest malignancy. The clue to the diagnosis lies in identifying multiple bronchiectasis in the right and left central lung fields (A, circles).

The lateral view confirms the opacity in the posterior segment of the RUL (B, arrow) and bronchiectasis in the anterior clear space (B, circle).

Central bronchiectasis accompanied by lung opacities are typical of diseases with thick tenacious mucus and are the hallmark of cystic fibrosis o allergic bronchopulmonary aspergillosis. Coronal and axial CT confirm the presence of numerous central bronchiectasis, one of them with a large mucous impaction (C and D, arrows).

In the mediastinal window the impacted mucus is increased in density (E and F, arrows), which is a pathognomonic sign of ABPA.

Final diagnosis: ABPA with central bronchiectasis and dense pulmonary impaction
 
Congratulations to MG who was the first to answer and made a valiant effort to diagnose a difficult case.
 
Teaching point: this case looks difficult, but the diagnosis is easy if we identify basic findings. Discovering central bronchiectasis narrows the diagnosis to two entities and CT confirms one of them.

Dr. Pepe’s Diploma Casebook 149 – All you need to know to interpret a chest radiograph – Third Session – SOLVED

~ Dr. Pepe ~ 8 Comments

Dear Friends,

I am showing today the leading image of the third webinar. If you haven’t seen them, you can see the first one here and the second one here:

Chest radiograph belongs to a 24-year-old man with occasional episodes of fainting, currently asymptomatic.

What do you see?

Come back on Friday and enjoy the recording of the third webinar with the answer to this case and more information!

Click here to see the answer

Findings: PA chest radiograph shows convexity of the right outline of the middle mediastinum (A, arrow), suggesting dilatation of the ascending aorta. Some of you have mentioned aortic coarctation, which is not a good option because rib notching is not visible, and the aortic knob is unremarkable.
Given the patient´s age, a good possibility is congenital aortic stenosis.

Enhanced sagittal CT reconstruction shows dilatation of the ascending aorta (B, asterisk) and heavy calcification of the aortic valve (B, arrow). Axial CT demonstrated a malformed and calcified aortic valve (C, circle).

Final diagnosis: congenital aortic valve stenosis with post-stenotic dilatation

Congratulations to Renga, who was the first to mention the ascending aorta dilatation.
 
Teaching point: the middle third of the mediastinum is occupied by the aorta and pulmonary artery. Any mediastinal abnormality in this area should be suspected to have a vascular origin.

You can see on our youtube channel the webinar Prof. Cáceres has prepared discussing this case and others.

Cáceres’ Corner Case 214 – SOLVED

~ Dr. Pepe ~ 21 Comments

Dear Friends,

Presenting today radiographs of an 89-year-old woman with dyspnea and moderate fever.

Diagnosis:

1. Empyema
2. Mediastinal tumor
3. Pneumonia
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows an opacity occupying the middle and lower right lung It is located anteriorly in the lateral view and has a well-defined posterior border.
The clue to the diagnosis lies with the bubbles of air within the opacity (A, red arrows) which resemble bowel loops in the lateral view (B, circle). The heart is displaced towards the left, but this finding cannot be evaluated because of the moderate scoliosis. In addition, a hiatus hernia is present (A-B, arrows).

Enhanced axial CT (C-D) demonstrates that the opacity consists mainly of fat containing some bowel loops.

Coronal and sagittal reconstructions show a large gap in the anterior right hemidiaphragm (E-F, circles), with herniation of bowel and abdominal fat into the hemithorax.

Final diagnosis: large Morgagni´s hernia simulating pulmonary disease.
 
Congratulations to xristoby, who was the only one who mentioned anterior diaphragmatic hernia.
 
Teaching point: Remember that any lower lung lesion adjacent to the diaphragm may arise from the abdomen, as demonstrated with the present case.

Dr. Pepe’s Diploma Casebook – All you need to know to interpret a chest radiograph – Second Session – SOLVED

~ Dr. Pepe ~ 2 Comments

Dear Friends,

Today I am presenting the leading case of the second webinar. The PA radiograph belongs to a 62-year-old man with hemoptysis.

Is the radiograph abnormal?
If so, what do you see?

Starting this week, I have decided to stop giving live webinars. They will be recorded and published at the end of the week, together with the answer to the case. You can see the first session here

Click here to see the answer

Findings: PA chest radiograph shows convexity of the aorto-pulmonary window (A, arrow) and an opacity in the upper left hilum (A, red arrow). The findings were not present in a film taken three years earlier (B, circle) and suggest a pulmonary process with mediastinal adenopathy.

Findings were overlooked and the chest was read as normal. Six months later the patient returned with acute right chest pain. PA chest shows two triangular pleural-based opacities (C, arrows) suggestive of Hampton’s humps. The convexity at the APW is larger (C, green arrow) and the hilar opacity has increased in size (C, red arrow).

Coronal CT shows the typical appearance of pulmonary infarcts at the right lung base (D, arrows). There is large adenopathy at the APW (D, green arrow) accompanied by a lung mass (D, red arrow).

Final diagnosis: carcinoma of the lung with mediastinal metastases and associated pulmonary infarcts.
 
Congratulations to S, who made a brilliant diagnosis.
 
Teaching point: Remember the importance of checklists. If a checklist had been used in the initial radiography, a CT would had been taken and the tumor would had been discovered earlier

If you would like to learn more about this subject, check the webinar Prof. Cáceres recorded explaining this cases and others! You can also check the first webinar here.

Cáceres’ Corner Case 213 – SOLVED

~ Dr. Pepe ~ 17 Comments

Dear Friends,

Today’s radiographs belong to a 46-year-old man.
Preoperative for knee surgery.

What do you see?

Leave your thoughts on the comments and come back on Friday to see the answer!

Click here to see the answer!

Findings: PA chest radiograph show increased size of both hila (A, arrows), more evident in the right side. There is also convexity of the aorto-pulmonary window (A, red arrow). The findings are highly suspicious of widespread lymphadenopathy, confirmed in the lateral view (B, arrow). There is also anterior bowing of the posterior tracheal wall by a rounded opacity in Raider´s triangle (B, red arrows).

Enhanced axial CT confirms enlarged hilar lymph nodes (C, arrows) as well as an adenopathy in the A-P window (D-E, red arrows).

The retrotracheal opacity was due to an aberrant subclavian artery arising from a Kommerel diverticulum (F-H, red arrows).

The patient had been diagnosed of sarcoidosis in 2015. Follow-up CTs in 2017 and 2019 did not show any change.
 
Final diagnosis: Sarcoidosis with an incidental aberrant right subclavian artery.
 
Congratulations to Manal Gebril, who was the first to make the diagnosis and to Gaborini, who described the aberrant right subclavian artery.
 
Teaching point: remember satisfaction of search. Some of you missed the occupation of Raider´s triangle and nobody mentioned the convex A-P window.