Dr. Pepe’s Diploma Casebook 166 – Big little findings

Dear friends,

I am starting a new section named “Big little findings”. The aim is to emphasize the importance of discovering subtle findings that should not be missed. They are easily seen if you know what to look for.

Today I’m showing preoperative chest radiographs of a 69-year-old man with bladder carcinoma.

What do you see?

Click here to see the answer

Findings: the most important feature is a negative finding: absence of air in the gastric fornix (A, circle). Although this is sometimes seen in healthy persons, it is more frequent in distal esophageal obstruction. A careful look discovers that the left mediastinum has a double contour, actually the left wall of the dilated esophagus (A, blue arrow) and the descending aorta (A, red arrow). There is bulging of the right paraesophageal line (A, yellow arrow). A dilated air-filled upper esophagus is visible in the lateral view (B, arrows).

The findings are typical of lower esophageal obstruction with dilatation of the esophagus. The double contour of the left mediastinum is better seen in the cone down view (C, arrows) and confirmed with CT (D, arrows).

The air-filled dilated esophagus in the lateral view (E, arrows) is confirmed with sagittal CT (F, arrows) (T= trachea).

Final diagnosis: unsuspected esophageal achalasia

To my eternal shame, I confess that when I read the initial radiographs I overlooked the findings (nobody’s perfect!). Achalasia was discovered in a routine follow-up CT taken one year later. I redeemed myself in a subsequent pre-op PA radiograph of the patient, in which I saw a double contour of the descending aorta (A and B, red and blue arrows) and bulging of the paraesophageal line (A and B, yellow arrows). I missed the absent air in the gastric fornix, again!

Esophageal achalasia is not an uncommon condition, and early stages can be suspected in the chest radiograph if we pay attention to the telltale signs. Note that these signs are not specific for achalasia and can be secondary to any obstructive process of the distal esophagus. The most revealing findings are:

Absent gastric bubble
Displaced lower mediastinal lines
Air-fluid level in the mediastinum


Occurs in about 10% of the normal population and 50% of achalasia patients, and is due to failure of swallowed air to cross the distal esophageal sphincter. It is a negative finding and therefore, difficult to recognize. When it is detected, we should examine the lower mediastinum, looking for signs of esophageal dilatation (Fig. 1).

Fig. 1. 54-year-old man with moderate dysphagia. In the PA radiograph, there is no gastric bubble (do not confuse air in the colon – A and B, black arrows – with air in the gastric fornix). The paraesophageal line is convex (A, red arrow). These two signs are suspicious for achalasia, confirmed with barium swallow. Note the distal esophageal stenosis (B, white arrow).


A dilated esophagus displaces the paraesophageal line toward the right, making it convex. The left wall of the esophagus moves outward, and is sometimes seen as a double contour with the descending aorta (Figs. 2 and 3). Convexity of the paraesophageal line is the most reliable sign and the easiest to detect.

Fig. 2. 48-year-old. woman with achalasia. Initial film shows a normal mediastinum with a visible gastric bubble (A, black arrow). Four years later (B) the gastric bubble is absent. There is a second contour (B, red arrow), paralleling the aorta (B, black arrow). Note that the initial concave paraesophageal line has become straight four years later (A and B, yellow arrows). Esophagogram confirms the esophageal dilatation and the narrow esophagogastric junction (C, red arrow).
Fig. 3. 47-year-old man with dysphagia. PA radiograph shows a convex paraesophageal line (A, white arrow). There is also a convex line on the left (A, red arrow). CT confirms the dilated esophagus containing air and fluid (B and C, asterisks). Diagnosis: esophageal achalasia.


Excluding hiatal hernia, an air-fluid level in the mediastinum is usually located in the esophagus. It is seen as a straight horizontal line in the middle/upper mediastinum. It is usually related to esophageal obstruction of any cause, the most common being achalasia. Discovery of an air-fluid level should lead us to investigate other signs of esophageal dilatation (Figs. 4 and 5).

Fig. 4. 47-year-old woman with dysphagia. PA radiograph shows an air-fluid level in the upper mediastinum (A, red arrow) accompanied by bulging of the paraesophageal line (A, white arrow) and absent gastric fornix. Esophagogram: dilated esophagus with distal stenosis (B, arrow) typical of achalasia.
Fig. 5. Showing this case because it’s a beauty. 73-year-old man referred by the pulmonologist to investigate chronic cough. PA and lateral chest radiographs show a dilated esophagus containing mainly air (A and B, white arrows), with a distal air-fluid level (A and B red arrows). Axial CT confirms the dilated esophagus with retained food (Insert, arrow). Achalasia, confirmed. Air is visible in the gastric fornix in this case (A, black arrow).

Aspiration pneumonia is a complication of achalasia. I’m showing two cases in which the signs mentioned helped to suggest the correct diagnosis (Figs. 6 and 7).


55-year-old man with pancreatic carcinoma and known achalasia who presented with marked cough. Chest radiographs show bilateral airspace infiltrates. In the PA view there is also dilatation of the upper esophagus (A, white arrows) with an air-fluid level (A, red arrow). The lateral view shows a retrocardiac mass (B, white arrow), suggestive of a dilated lower esophagus. The trachea is displaced forward (B, red arrow). These signs were overlooked by the radiologist, whose diagnosis was widespread pneumonia.

Coronal CT demonstrates widespread air-space disease. It also shows a dilated esophagus (C, arrow). Axial CT images confirm dilatation of the esophagus, which is full of residue
(D and E, arrows).
Final diagnosis: esophageal achalasia with secondary aspiration pneumonia.


This an old case of a 27-year-old woman with a chronic RUL opacity suspected to be TB (disregard the opacities in both middle lung fields, caused by superimposed breast implants).
PA chest radiograph shows an opacity in the right upper lobe (A, circle). A right paramediastinal line extends from top to bottom (A, arrows). The lateral view shows anterior displacement of the trachea by a tubular structure (B, arrows), which occupies the upper and middle mediastinum. Both findings suggest a dilated esophagus.
Barium swallow confirms the dilated esophagus, secondary to narrowing at the esophagogastric junction (insert, arrow). Considering the age of the patient, achalasia with aspiration pneumonia was the most likely diagnosis, confirmed later.
(Remember that aspiration pneumonia goes to the right upper lobe when the patient is recumbent at night).

Follow Dr. Pepe’s advice:

Subtle findings of distal esophageal obstruction (achalasia) that should not be overlooked:

1. Absent gastric bubble

2. Displaced lower mediastinal lines

3. Air-fluid level in mediastinum

Cáceres’ Corner Case 250 – SOLVED

Dear Friends,

Welcome to the year 2021! Beginning with an easy case: chest radiographs of a 76-year-old man with pain in the left hemithorax.

What do you see?

More images will be shown on Wednesday.

Click here to see Monday images

Dear friends, showing today CT images of the chest and abdomen.
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA radiograph shows a well-defined opacity in the right apex (A, arrow). The posterior arch of the third rib is missing (A, asterisk). These findings were not present in a previous radiograph taken five years earlier (B).

Lateral view shows a posterior extrapulmonary mass (C, arrow), better seen in the cone down view (D, arrow).

The findings are indicative of a lytic rib lesion accompanied by an extrapulmonary mass. The most likely etiology in the adult is a malignant process, either metastasis or myeloma. A benign process such as fibrous dysplasia usually increases the size and the density of the bone. The location and the well-defined border goes against a Pancoast tumor.

Axial and sagittal CTs confirm the extrapulmonary mass (E-F, arrows) as well as the destroyed third rib (F, circle).

Axial CT of the upper abdomen demonstrates a mass in the tail of the pancreas (G, circle). Needle biopsy confirmed the diagnosis of pancreatic carcinoma.

Final diagnosis: pancreatic carcinoma with metastases to the left third rib

Congratulations to Mestasmarcos who was the first to suggest metastasis in the plain film.
Teaching point: Remember that a lytic rib lesion in the adult should be considered malignant (metastasis vs myeloma) until proven otherwise.

Dr. Pepe’s Diploma Casebook 165 – SOLVED

Dear Friends,

showing today a preoperative AP chest of a 93-year-old man who broke his right femur after a fall.

What do you see?

Click here to see the answer

Findings: AP chest radiograph shows a poorly defined opacity in the RUL (A, circle).

Axial and coronal enhanced CT show that the opacity corresponds to a tortuous brachiocephalic artery (B and C, arrow). There is no pulmonary infiltrate.

Final diagnosis: Tortuous brachiocephalic artery simulating a pulmonary infiltrate.

The aim of this Diploma is to continue discussing chest imaging in the older population.

Today I will comment about the main manifestations of aging in the mediastinum and heart, discussing variants that may simulate disease, followed by the most common conditions affecting these regions in elderly patients.


The standard PA radiograph in aging adults usually shows a somewhat enlarged mediastinum, due to poor inspiratory effort combined with an elongated aorta and mediastinal fat accumulation (Fig. 1) .

Fig. 1. Normal chest in an 85-year-old man. Note the limited inspiration and increased width of mediastinum. The aorta is elongated, and the cardiothoracic ratio is 50%. A pacemaker is visible in the left hemithorax.

A common variant in older patients is a tortuous brachiocephalic artery, which may project into the lung, simulating a pulmonary lesion (Fig. 2), as was shown in the initial case.

Fig. 2. 88-year-old woman with vague chest complaints. PA radiograph shows an RUL opacity (A, circle). Unenhanced axial CT confirms that the opacity corresponds to a tortuous brachiocephalic trunk projecting into the lung (B, arrow).

Sometimes the tortuous artery simulates a mediastinal mass. In these cases, the diagnosis is easy because a mediastinal mass pushes the trachea toward the left (Fig. 3A), whereas an elongated artery does not; instead, the associated elongated aorta displaces the trachea to the right (Fig. 3B).

Fig. 3. 52-year-old man with a right thyroid mass pushing the trachea towards the left (A, arrow).
The second patient is an 83-year-old man with tortuous brachiocephalic vessels simulating a mediastinal mass (B, arrow). Note that the trachea is displaced towards the right by an elongated aorta.

The aorta is elongated in most older adults. A kink in the distal descending aorta often casts a posterior shadow in the lateral view that should not be confused with disease (Fig. 4).

Fig. 4. 73-year-old man with an elongated aorta (A). A kink in the descending aorta creates a posterior opacity superimposed on the lower spine (B, circle). Unenhanced sagittal CT confirms the kink as the cause of the opacity (insert, arrow).

Calcification of the annulus fibrosus of the mitral valve is common in elderly individuals. It does not cause symptoms and should not be confused with other conditions. It has a pathognomonic appearance in the chest radiographs (Fig. 5).

Fig. 5. 79-year-old man/woman with mitral annulus calcification. Note the typical “C” shape and location in the PA and lateral radiographs (A and B, circles).

A variant of calcified annulus fibrosus is a condition termed caseous necrosis of the mitral annulus. It appears as an ovoid intracardiac calcification, visible in chest radiographs (Fig. 6) and confirmed with CT. It is also symptomless.

Fig. 6. 73-year-old man, asymptomatic. PA and lateral radiographs demonstrate an ovoid calcification projected over the cardiac shadow (A and B, arrows). Axial CT confirms the calcification (insert, arrow), corresponding to caseous necrosis of the annulus.


The most common mediastinal pathology in the older population is hiatus hernia, easily identifiable when it contains air. An airless hernia should not be confused with a lower mediastinal mass. The best way to diagnose hiatus hernia is by looking at previous films (Fig. 7). If none are available, a barium swallow is sufficient (Fig. 8).

Fig. 7. 68-year-old woman with an airless hiatus hernia simulating a mediastinal mass (A, arrow). Previous film one year earlier shows a typical hernia with an air-fluid level (B, arrow).
Fig. 8. PA and lateral radiographs in a 65-year-old woman with a large airless hiatus hernia (A and B, arrows) . No previous films. Barium swallow confirms the hernia (insert, arrow).

At times, too much air in a hernia may be misleading, as occurred in the case below, which was initially diagnosed as a possible pneumopericardium (Fig. 9).

Fig. 9. 66-year-old woman with known breast carcinoma admitted to the ER in shock. AP radiograph show right lung metastasis (A, arrow) and two lines outlined by air surrounding the heart (A, red arrows).

Pneumopericardium was suspected. Enhanced CT coronal and sagittal images
show that the apparent pneumopericardium was actually a large hiatus hernia (B and C, arrows). On retrospective review of the patient’s chest radiograph, bowel air can be seen projected over the heart.

Mediastinal mass in patients of advanced age are commonly due to metastasis. Lymphoma is an alternative diagnosis, as around 50% of non-Hodgkin lymphomas occur in patients older than 65 years (Fig. 10).

Fig. 10. 77-year-old woman with asthenia and weight loss. Chest radiographs show bilateral pleural effusion and an anterior mediastinal mass (A, arrows. B, asterisk). Axial CT confirms
the mass (insert, arrow). Diagnosis: B-cell lymphoma

Differentiating aortic aneurysm from a tortuous aorta is difficult in chest radiographs, because the medial aortic wall is obscured by the mediastinum. Sometimes the inner wall is outlined by air, allowing detection of aortic dilation in the plain film (Fig. 11).

Fig. 11. 73-year-old woman with chest pain and a tortuous aorta. The medial wall is outlined by air, allowing us to determine that the aorta is dilated (lines in A and B). Enhanced axial CT shows a type-B aortic dissection (insert, arrow).

The incidence of atrial fibrillation increases after the age of 65, and up to 9% of octogenarians are affected with this condition. Detecting a prominent left atrium in the chest radiograph of an elderly person should suggest this diagnosis (Fig. 12).

Fig. 12. 75-year-old woman with atrial fibrillation. Note the prominent left atrium in the PA and lateral radiographs (A and B, arrows).

Ventricular aneurysm is a complication of myocardial infarction. In an elderly patient, the aneurysm may calcify and appear as curvilinear calcium projected over the left heart (Fig. 13).

Fig. 13. 80-year-old man with a history of myocardial infarction ten years earlier. Chest radiographs show a thin curvilinear line projected over the heart, consistent with a calcified aneurysm (A and B, arrows). Unenhanced CT confirms the diagnosis (insert, white arrows). A calcified thrombus is also visible (insert, red arrow).

Follow Dr. Pepe’s advice:

1. Tortuous brachiocephalic artery and calcification of the mitral annulus are common variants in persons of advanced age.

2. Hiatus hernia occurs frequently in older individuals.

3. Enlarged left atrium in this age group should raise the possibility of atrial fibrillation.

This is the last case on 2020 and we will be back on January 11, 2021!

Cáceres’ Corner Case 249

Dear Friends,

today I am presenting the PA chest radiograph of a 77-year-old man who came to the Emergency Room with severe dyspnea.

How many significant findings do you see?

1. One
2. Two
3. Three
4. Four

Click here to see the answer

Findings: AP chest radiograph shows an opaque left hemithorax with displacement of the mediastinum towards the right. The splenic flexure of the colon is pushed downwards (A, arrow) a sign of left diaphragmatic inversion. The appearance of the chest is typical of a massive left pleural effusion. In addition, there are two nodular opacities in the right lung (A, red arrows). There is a lytic lesion of the left third rib (A, white arrow) and the anterior arch is missing (A, asterisk).

These findings are better seen in the cone down views (B-C, arrows). They are highly suggestive of widespread malignant disease.
The patient had a cardiac arrest in the ER and could not be reanimated. Autopsy demonstrated a gastric carcinoma with multiple metastases.

Final diagnosis: Metastases to the chest from carcinoma of the stomach

Congratulations to Rafał, who was the first to see the lytic lesion in the left third rib.
Teaching point: Although the main finding is very obvious (massive pleural effusion), detecting the nodules and the lytic lesion of the rib is the clue to the correct diagnosis of malignancy.
Remember satisfaction of search!

Dr. Pepe’s Diploma Casebook 164 – SOLVED

Dear Friends,

Today I will show a new “Meet the examiner case”, with questions and answers similar to a real presentation. You will get more images on Wednesday and the final answer on Friday.

Images belong to a 49-year-old woman with progressive chest pain and dyspnea. She mentions being hit in the chest with a surfboard three weeks ago.

1. Myocardiopathy
2. Pericarditis
3. Myelolipoma
4. Any of the above

What do you see?

Click here to see more images

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid (A)

Three days days later the patient developed mild symptoms of cardiac tamponade. Portable chest (B) shows increased size of the cardiac silhouette. Enhanced axial CT (C) is shown.
What do you think?

Click here to see the answer

Findings: PA and lateral radiographs (A-B) show what appears to be an enlarged cardiac silhouette. Of the offered options I would think first of pericardial effusion because the pulmonary vessels are small compared to the size of the heart. In cardiomyopathy I would expect engorged pulmonary vessels. Cannot exclude thymolypoma, but I would consider it very unlikely. Probably the best answer is 4. All of the above. And I would recommend a cardiac US because traumatic pericardial effusion is the most likely diagnosis.

Cardiac ultrasound discovered a large pericardial effusion that was drained, evacuating a large amount of hematic fluid. Note the normal thickness of the pericardium (C-D, arrows)

CT also discovered healing fractures of the anterior 4th, 6th and 7th left ribs (E-G, arrows)

After drainage, the heart shadow returned to normal size (H). Three days later the patient developed fever and mild symptoms of cardiac tamponade. Portable chest showed increased size of the cardiac silhouette, despite the presence of a draining catheter (H-I, red arrows).

Enhanced CT demonstrated a moderate amount of pericardial fluid (J-K, arrows) accompanied by bilateral pleural effusions (J, red arrows). The pericardium was surgically explored and cleaned. Staphylococcus Xilosus was grown.

After appropriate antibiotic treatment the symptoms subsided. One month later the chest at discharge appeared normal (L-M).

Final diagnosis: delayed traumatic pericarditis with subsequent infection

Pericardial effusion has many causes, one of them blunt trauma. It is usually associated with other findings: pneumothorax, fractured ribs and lung contusion. Delayed pericardial effusion is a rare manifestation of previous blunt trauma.

Plain film signs of pericardial fluid are unreliable, except for visualization of posterior displacement of epicardial fat in the lateral view, which has high value (epicardial fat sign, Fig. 1). Cardiac ultrasound is the diagnostic technique of choice.

I am showing this case because of the beauty of the initial images and the iatrogenic infectious complication, which muddled the differential diagnosis.

To complete the presentation I am showing a very rare case of cardiac volvulus. It occurred secondary to surgical trauma, after removal of part of the right pericardium (Fig. 2).

I borrowed this case from an American friend a long time ago and am ashamed to confess that I don’t remember who he was. The credit is yours, friend. Many thanks.

Fig. 1. 46-year-old man with liver cirrhosis and pericardial effusion. PA radiograph(A) shows non-specific enlargement of the cardiac silhouette. The lateral view shows posterior displacement of the epicardial fat (B, arrow). The thickened pericardium is visible between the epicardial and mediastinal fat (B, red arrows).

Coronal and sagittal CT confirm the presence of a moderate amount of pericardial fluid (C-D, arrows). Note the displaced epicardial fat in the lateral view (B, red arrow).

Fig 2. 34-year-old woman with Down syndrome with chronic respiratory infections in RLL (A). Bronchoscopy discovered a hemangioma obstructing the intermediary bronchus. At surgery the tumor was adherent to the right pericardium. Pneumonectomy and partial resection of right pericardium were performed.
Post-op portable chest shows moderate prominence of the right heart border (B, arrow).

Six hours after the intervention the patient started to deteriorate and went into shock. Portable radiograph shows displacement of the cardiac silhouette to the right (C, arrow) and complete herniation of the heart into the right hemithorax twelve hours later. (D, arrow). A second intervention confirmed a cardiac volvulus that was corrected with a pericardial patch.

Follow Dr. Pepe’s advice:

1. Delayed pericarditis after blunt trauma is rare. Should be considered when the cardiac silhouette enlarges following blunt chest trauma

2. Echocardiography is the diagnostic method of choice for diagnosing pericardial fluid

3. Plain film signs of pericardial effusion are unreliable, except for visible displaced epicardial fat in the lateral radiograph

Cáceres’ Corner Case 248 – SOLVED

Dear Friends,

today I am showing preop radiographs for knee surgery of a 71-year-old man.
What do you see?

More images will be shown on Wednesday.

Click here to see new images

Dear friends, showing additional images of the sternum taken six years earlier, in 2014.
What do you think?

Click here to see the answer

Findings: PA chest is unremarkable (A). The lateral radiograph shows an expanding lytic lesion in the sternal manubrium (B, circle).

Cone down view shows the lesion better (C, arrows). Sagittal, coronal and axial unenhanced CT taken six years earlier (2014) demonstrate that the cortical bone is broken in several places, suggesting an aggressive process (D-F, arrows). A soft-tissue mass is not visible.

No other skeletal lesions were found. Biopsy of the sternum confirmed the diagnosis of solitary myeloma (plasmocytoma), that was subsequently treated. The patient remained asymptomatic.
Final diagnosis: Plasmocytoma of the sternum
Congratulations to Priyanka Chhabra and Olena, who made the correct diagnosis. And kudos to all of you who saw the lesion in the lateral chest radiograph.
Teaching point: Remember that a lytic lesion of the sternum in an adult is malignant until proven otherwise. Main etiologies are primary tumors (chondrosarcoma) and metastases.

Reviewing the literature, I found a case report with similar findings: Solitary plasmacytoma of the sternum with a spiculated periosteal reaction: A case report. ONCOLOGY LETTERS 9: 191-194, 2015

Dr. Pepe’s Diploma Casebook 163 – SOLVED

Dear Friends,
I am back with a new Diploma case. Miss Piggy sends her regards😍 and has helped to choose the case.
Chest radiographs belong to a 74-year-old man with a cough and pain in the chest.

What do you see?

Click here to see the answer

Findings: PA radiograph shows a bulge in the left paraspinal line (A, arrow), suggestive of a posterior mediastinal mass. A rounded posterior opacity is seen in the lateral view (B, arrow).

Unenhanced coronal and sagittal CT show large osteophytes displacing the paraspinal line (C, circle) pushing the aorta forward in the sagittal view(D, circle). Incidental gas is visible in the intervertebral disk.

Final diagnosis: large osteophytes simulating a pulmonary/mediastinal mass

The aim of this Diploma is to discuss chest imaging in the elderly. As patients get older the appearance of their chest radiographs changes in comparison with young persons. I intend to discuss changes associated to aging as well as the most common pathologies in the old.

I have divided the presentation into three separate chapters:

1- Bony structures of the chest
2- Heart and mediastinum
3- Lungs and diaphragm

Today I will comment on the main manifestations of aging in the chest skeleton, discussing variations that may simulate disease, followed by the most common bone pathologies in the elderly.


Degenerative changes are the hallmark of the aging skeleton.Vertebral osteophytes are common and large ones should not be confused with pulmonary nodules (Fig 1) or mediastinal masses (Fig 2), as shown in the initial case. The diagnosis is easily made with chest CT.

Fig 1. 67-year-old male without significant symptoms. PA radiograph (A) is unremarkable. Lateral view shows a posterior nodule that could be intrapulmonary (B, arrow).

Coronal and sagittal unenhanced CT show that the nodule represents a large osteophyte (C-D, arrows). The absence of other osteophytes makes it difficult to suspect this diagnosis in the plain film.
Fig 2. 65-year-old man in whom a posterior mediastinal mass was discovered (A-B. arrows). The mass was unchanged in comparison with a previous examination. CT was recommended because a neurogenic tumor could not be excluded.
Unenhanced coronal and sagittal CT demonstrates that the mass represents a single large osteophyte (C-D, arrows)

Calcification of the first costal cartilage may happen in the young but it is more common in the elderly. When asymmetrical, it may be confused with a pulmonary nodule (Fig 3). Exuberant cartilage calcification may simulate an upper lobe infiltrate (Fig 4).

Fig 3. 70-year-old man with a large pleural effusion, suspected to be malignant because of a possible nodule in the LUL (A, arrow). Cone down view shows that the nodule es calcified and corresponds to the first costal cartilage (B, arrow). Post-pneumonic empyema.
Fig 4. 69-year-old woman with fever. Exuberant calcification of the first right costal cartilage was initially diagnosed as pneumonia (A, circle). Comparison with a radiograph taken four years earlier did not show any change (B-C, arrows).

Aging causes brittle bones and explains the increased incidence of costal fractures in the elderly. The callus of a healed fracture should not be confused with a pulmonary nodule (Fig. 6).

Fig 6. 74-year-old woman in whom a RUL nodule appeared one year after cardiac surgery (A, arrow).
A 3-D reconstruction shows that the nodule represents a healed fracture of the second rib (B, circle). Ribs fractures after cardiac surgery are not uncommon

Resuscitation maneuvers, not uncommon in advanced age, may cause bilateral rib fractures, that should be recognized as such (fig 7).

Fig 7. 63-year-old man with prostate carcinoma, complaining of chest pain. PA radiograph shows
sclerotic areas in the lower ribs (A, arrows), not present in previous films. My initial impression was metastatic disease, until I learned that the patient has had resuscitation maneuvers a few months earlier. Axial and coronal CT confirms symmetrical healed fractures of the anterior lower ribs (B-C, circles).


The most common bone pathology in the elderly are fractures. Acute rib fractures are common, most of them secondary to falls (Fig 8). Detection is important because they cause respiratory impairment that may end in pneumonia with the subsequent increase of morbidity and mortality.

Fig 8. 78-year-old alcoholic man after a fall. PA radiograph shows displaced rib fractures (A, circle) as well as pneumothorax (A, red arrow) and subcutaneous emphysema Note the straight air-fluid level of hemothorax at the left base (A, arrow)

Compression fractures of vertebral bodies are related to osteoporosis and common in the elderly. They cause significant pain, leading to inability to perform daily activities. If they are not recognized they cause a decline of the quality of life in elderly patients (Fig 9).

Fig 9. 84-year-old woman with chronic back pain. PA radiograph (A) is unremarkable. Lateral chest shows a severe compression fracture of D9 (B, circle), better seen in the cone down view (C, arrows).

Lytic bone lesions in the elderly are usually related to metastases or multiple myeloma. Sclerotic metastases are common in old males. Given the prevalence of prostate carcinoma this should be our first diagnostic consideration in widespread sclerotic lesions (Fig 10). The differential diagnosis includes myelofibrosis (fig 11) and chronic renal failure (Fig 12).

Fig 10. 71-year-old male with widespread sclerotic lesions of ribs and spine secondary to metastases from prostatic carcinoma.

Myelofibrosis is a myeloproliferative neoplasm which cause osteosclerosis. The association of an enlarged spleen should alert us to this possible diagnosis.

Fig 11. Preoperatory chest film in a 67-year-old woman. Diffuse increased bone density (A), better seen in the cone down view of left shoulder (B). The medially displaced gastric bubble suggests splenic enlargement (A, arrow). Myelofibrosis suspected and confirmed.
Fig 12. 73-year-old woman with chronic renal failure. PA radiograph (A) shows deformity of the rib cage. Lateral view (B) show the rugged-jersey spine, typical of this entity.

Solitary sclerotic lesions of the skeleton raises the possibility of metastasis vs. Paget disease. In the spine, Paget disease usually increases the size of the vertebra whereas metastases do not (Fig 13). In the peripheral skeleton the increase in width of the cortical bone is characteristic of Paget disease (Figs 14-15) .

Fig 13. 68-year-old man who presented with back pain. PA radiograph (A) is unremarkable. Lateral view shows an ivory vertebra (B, circle) that has the same size than the others.
Diagnosis: metastasis from prostatic carcinoma.
Fig 14. Two patients with Paget disease of a rib. Note the increased cortical thickness of the 6th rib in the first patient compared to the other ribs (A, arrow) a hallmark of Paget disease. The second patient has sclerosis of the whole 6th rib which is increased in size
(B, arrow), another characteristic of Paget.
Fig 15. 70-year-old man with prostate carcinoma and metastasis to the anterior third rib (A-B, arrows). Note the difference with the previous cases.

Follow Dr. Pepe’s advice:

1. Osteophytes and healed rib fractures may simulate pulmonary nodules in the elderly

2. It is important to detect rib or vertebral fractures in the elderly because they may be the source of complications

3. Sclerotic bone lesions in the elderly are usually due to prostate metastases or Paget disease

Cáceres’ Corner Case 247 – SOLVED

Dear Friends,

Today´s radiographs belong to a 53-year-old man with abdominal pain.
What do you think?

Dear Friends,

showing today axial and coronal CI images of the abdomen. What do you think?

Click here to see new images

Click here to see the answer

Findings: PA and lateral chest radiographs show a large gastric bubble, with abundant stomach contents (A, arrow). In addition, there is a prominent air-fluid level in the right upper quadrant (A-B, red arrows), A small rounded metallic opacity is projected over it in the lateral view (B, circle).
The findings are suggestive of gastric outlet obstruction. Duodenal obstruction is unlikely because the second air-fluid level is anterior in the lateral projection. The little rounded metallic opacity suggests the possibility of a foreign object.

Coronal and axial CT show a food-filled stomach with a balloon located in the antrum (C-D, arrows).

Upright abdominal radiograph (E), parallels the gastric findings in the coronal CT (F).
(Showing plain film of the abdomen as an homage to Dr Genchi Bari).
A gastric balloon for obesity had been placed two weeks earlier.

Final diagnosis: balloon causing stomach outlet obstruction. This complication occurs in less than 1% of cases (*).
Congratulations to Olena, who was the only one to see the balloon valve and to Archanereddyt who made the final diagnosis.
Teaching point: as stated in case 242, always include iatrogenesis in your differential diagnosis. Reviewing the literature I discover an interesting fact: the saline in the balloons is tinted blue. If the urine becomes blue or green, is a sign of balloon deflation.
Incidentally, malicious rumors about the radiographs belonging to Miss Piggy are totally false!
(*) Gastric outlet obstruction secondary to orbera intragastric balloon. SA Kook and J Hammond. JSCR 2018; 10: 1-3

Dr. Pepe’s Diploma Casebook 162 – SOLVED

Dear Friends,

taking advantage of Dr Pepe’s absence I am showing today an unproven case (always wanted to do it!). All relevant images are shown, without comment, looking forward to hear your opinions.
I will share my impressions with you next Friday. Hope we will coincide. We have to wait together until we get the final diagnosis (or not).

Chest radiographs belong to a 66-year-old man with abdominal pain and a history of diverticulitis. The round opacity at the left base led to a review of previous examinations, dating back to 2007.

Abdominal CT for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus

The patient had recurrent episodes of diverticulitis and/or abdominal pain. I am offering several axial CTs in different years to document the evolution of the lesion

Occasionally the chest was also examined. Showing three samples of sagittal CTs with pulmonary window over a ten years’ period.

The last abdominal CT was taken on August 30, 2020. I have selected the most relevant axial, coronal and sagittal images.

Have you reached a conclusion after reviewing all the images?

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The case starts in 2019 with chest radiographs of a 66-year-old man with abdominal pain and previous history of diverticulitis. A rounded opacity is seen the left lung base (A-B, arrows). This finding led to a review of previous examinations, dating back to 2007.

Abdominal CTs for diverticulitis in 2007 and 2008 show a cystic lesion in the left costophrenic sinus(C-D, circles). The lesion has grown slightly in one year.

Since 2007 the patient had recurrent episodes of diverticulitis and/or abdominal pain. Several abdominal CTs in different years document the evolution of the lesion: the purely cystic lesion in 2008 (E, arrow) has grown in 2013 and fine septa are seen within it (F, circle).
CT in 2015 shows that the septa are thicker and enhance after contrast injection (G, circle). An unenhanced CT in 2018 demonstrates a smaller lesion with a thick peripheral rim of solid tissue (H, arrows).

Sometimes the chest was included in the CT examination. Three samples of sagittal CTs with pulmonary window over a ten years’ period show that the lesion lies within the left major fissure (A-C, arrows). It looks like a pendulum held by the fissure and has an irregular contour in the last image in 2018.

A final unenhanced abdominal CT taken on August 2020 shows that the appearance of the lesion has not changed significantly in the last two years. In the meantime a small punctate calcification has appeared (L and O, arrows).

Conclusion after review of the images:

1- Slow-growing mass over a period of ten years.

2- The initial cystic mass has developed thick septa and thick peripheral rim.

3- Located within the left major fissure.

4- Punctate calcification.

Given all these finding, my best option is a fibrous pleural tumor of the left pleural fissure which is undergoing malignant transformation.

An alternative diagnosis could be a mucinous pleural tumor if such entity exists.
In my opinion, hydatid cyst is very unlikely. It has been practically eradicated from Spain and I have never seen one within a fissure.

The patient is now in the hands of a competent pneumologist. Hope we will get a definitive diagnosis soon. As soon as I get it, I will post it in the blog ( and, if it happens to be a hydatid cyst, I will do penance in a nunnery).

Cáceres’ Corner Case 246 – SOLVED

Dear Friends,

Today I am showing the PA radiograph of an 82-year-old woman. Preoperatory for cataracts.

What do you think about the right hilum?

1. Calcified TB nodes
2. Sarcoidosis
3. Amyloid
4. None of the above

More images will be shown on Wednesday.

Click here to see the images shown on Monday

Dear friends, showing today PA and lateral radiographs taken two years earlier. Hope they help.

Click here to see the new images

Click here to see the answer

Findings: Initial PA radiograph shows opacities in the right hilum (A, circle), unchanged in comparison with a previous film taken two years earlier (B, circle).

The clue to the diagnosis lies in the density and appearance of the opacities. They are denser than the typical lymph node calcifications, suggesting that they are metallic. In addition, some of them look tubular or branching (C, red arrows). A lateral view taken two years earlier confirms dense lineal and branching opacities in right lung (D, arrows).
The combination of linear and branching metallic opacities suggests that they are either in the bronchi (previous bronchography) or within the pulmonary vessels (embolism after vertebroplasty o treatment of AV malformation). See Diploma # 44.

Lateral view of the lumbar spine shows surgical changes with vertebroplasty of L3 to L5 and leakage of the cement into the epidural veins (E, arrows), better seen in the sagittal CT (F, arrows).

Unenhanced CT confirms multiple cement emboli in the pulmonary arteries (G-J, circles)

Final diagnosis: cement embolization of the lung after vertebroplasty
I must mention Olena and Ayudi who suggested amyloid and broncholithiasis but failed to notice the metallic opacity of the findings.
Teaching point: Consider previous vertebroplasty when you see metallic opacities in the lungs. It is a common complication.