Dr. Pepe’s Diploma Casebook 161 – Meet the examiner

Dear Friends,

This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.

The images belong to a 60-year-old man with moderate cough and dyspnea

What would you recommend?

1. Compare with previous films
2. Chest CT
3. PET-CT
4. None of the above

Click here to see the answer

Findings: PA radiograph shows large bullae in both upper lobes. There is a nodule in the RUL projected over one bulla (A, arrow). Two small calcified granulomas are visible in the periphery of the LUL (A, circle). PA film taken five years earlier (B) does not show any nodule in the RUL. The granulomas in the LUL are unchanged.

Report of the chest : bullous emphysema with a nodule not visible in 2014. Given the relationship between bullous disease and carcinoma, it is imperative to do a chest CT.

Enhanced CT was done the next day. What would you suggest?

1. Antibiotic treatment and CXR in one month
2. PET-CT
3. Antibiotic treatment and CT in one month
4. None of the above

Click here to see the answer

Findings: aside form large bullae in both upper lobes, an irregular nodule is evident in the RUL (A-B, arrows). In my opinion, given the appearance of the nodule I would suspect malignancy and request a PET-CT. However CT was reported as: Pseudonodular opacity in RUL that could be related to an infectious/inflammatory process. A neoplasm cannot be excluded. Recommend control after treatment

Click here to see more images

A chest radiograph was taken one month later.
What would you do?

1. PET-CT
2. CXR in three months
3. CT in three months
4. Control in one year

Click here to see more images

The chest radiograph one month later was reported as unchanged and no further suggestions were made by the radiologist. The clinician took no further action.

The patient came back ten months later, and a new radiograph showed an obvious increase in size of the nodule (B, arrow) when compared to the initial film (A, arrow)

Click here to see more images

Enhanced CT confirms the increase in size of the nodule (A-B, arrows). Surgery discovered a carcinoma in the wall of a bulla.

Final diagnosis: adenocarcinoma of the lung associated to bullous disease.

Lung carcinoma seems to occur more often in bullous disease, although there is not enough evidence compiled at the present time. Despite the lack of evidence, knowing
this association may prevent misdiagnosis.
A lesser known fact is that the cystic space may disappear after the carcinoma develops, as occurred in a second case (see below). Spontaneous regression of a bulla may be due to non-malignant causes, but carcinoma should be excluded with CT because it may take years for the lesion to be visible in the chest radiograph.

I am showing this case because the opinion given in the chest radiograph was unequivocal, whereas the CT report was vapid, giving the impression that the nodule was infectious, and that malignancy was less likely. The follow-up radiograph was disregarded by the radiologist and clinician and this caused a delay in diagnosis of almost one year.

To complete the information, I am showing a second case of carcinoma developing in the wall of a cystic space

Images of the second case were obtained during routine CT screening in a 72-year-old man, heavy smoker.
Apical axial CT image shows a small nodule in the LUL (A, arrow), with increased uptake on PET-CT (C, arrow). There is a cystic airspace in the LLL (B, arrow) with no PET-CT uptake, interpreted as a non-specific cystic airspace lesion.

At surgery a carcinoma of the LUL was found.

It was decided to continue with yearly follow-up studies. The cystic air space (A, arrow) increased in size in 2008 but still had a thin wall (B, arrow). In 2009 it has decreased slightly in size and the wall is thicker than the previous year (C, arrow). A new PET-CT shows increased uptake in the posterior wall (D, arrow).

Malignancy was suspected. The patient refused further surgery or percutaneous biopsy and it was decided to do a follow up study three months later.
Axial CT shows that the cystic airspace has disappeared and in its place, a solid mass has developed (A and B, arrows) with increased overall uptake on PET-CT (C, arrow). At surgery, an adenocarcinoma was found.

Final diagnosis: adenocarcinoma arising in the wall of a cystic airspace, which disappeared as the tumour progressed.


Follow Dr. Pepe’s advice:

1. Bullous emphysema and isolated cystic spaces may be associated with an increased incidence of carcinomas

2. A poorly worded report may cause an unnecessary delay in diagnosis

Cáceres’ Corner Case 245 – SOLVED

Dear friends, Dr Pepe has eloped with Miss Piggy (again) and has let me alone, holding the fort. Hope he will be back in time to give the next webinar.

Today’s radiographs belong to a 60-year-old male with cough and moderate dyspnea.

Diagnosis:

1. Hilar lymphadenopathy
2. Right pulmonary artery aneurysm
3. Mediastinal tumor
4. None of the above

Click here to see the answer

Findings: PA and lateral chest radiographs show a right hilar mass (A-B, arrows). In my opinion, the appearance of the mass and its location in the right hilum in the lateral view rules out a mediastinal mass.
There is a small nodule in the RUL (A, red arrow) that can be overlooked unless we look for it

The nodule is better seen in the cone down view and the axial CT (C-D, red arrows), with high SUV in the PET-CT (E, arrow), accompanied by a metastatic node in the mediastinum (E, circle).

Caudal slices of enhanced CT show multiple lymph nodes in right hilum (F, arrow) and mediastinum (G, circle).

Biopsy of a lymph node returned as metastatic carcinoma.

Final diagnosis: carcinoma of the lung with mediastinal metastases

Congratulations to archanareddyt who was the only one to discover the RUL nodule

Teaching point: this is an interesting case for educational purposes.
1. Knowing the most common causes of unilateral hilar enlargement (lymph nodes vs. enlarged artery) helps the differential diagnosis.
2. We should think of common processes rather than unusual ones (lymph nodes vs. aneurysm).
3.  Suspecting unilateral hilar lymph nodes leads to search for the two more common etiologies (TB or carcinoma) leading to the discovery of the RUL nodule.

Hope the case was useful!

Cáceres’ Corner Case 244 – SOLVED

Dear friends I am presenting today the pre-op PA chest radiograph of a 40-year-old man.
What do you see?

More images will be shown on Wednesday.

Click here to see more images

Dear friends, showing today images of the barium swallow. What do you think?

The answer will be published on Friday 🙂


Click here to see the answer

Findings: PA radiograph shows convexity of the middle aspect of the right mediastinal border (A, arrow). There is a double contour in the opposite side (A, red arrow). These two lines conform the limits of a rounded mass which is better seen in the penetrated AP radiograph (B, arrows).

An outside CT (not available) confirmed a middle mediastinal mass. Esophageal diverticulum was included in the differential diagnoses (??) and for this reason a barium swallow was done.

AP view of the esophagogram shows a large mass deforming the esophagus (C, circle). Oblique view demonstrates the typical appearance of a submucosal mass of the esophageal wall (D, circle). Endoscopy confirmed an intact mucosa.
A large intramural esophageal tumor that looks like an alien was resected (E, insert)

Final diagnosis: leiomyoma of esophagus.
 
Congratulations to Traidor who made the diagnosis before the barium study and to Genchi Bari, after.

Teaching point: I am showing this case to review basic concepts of paleo-radiology (before CT), when we used to classify GI tumors according to the appearance of the filling defect in the barium column.

A represents an intraluminal mass (polyps and carcinomas, usually)

B is the typical appearance of a submucosal intramural mass (looks like an extrapulmonary lesion in the chest radiograph). Usually due to benign spindle-cell tumors or duplication cyst. Rarely metastasis.

C represents the deformity secondary to an extrinsic mass

Dr. Pepe’s Diploma Casebook 160 – With a webinar! – SOLVED

Dear friends, I am starting a new webinar series entitled “Things that we already know, but are important to remember”. The objective is to refresh basic concepts that often are forgotten.

This week’s webinar title is “Who is afraid of the bad, big lateral chest”. The webinar will take place on Wednesday, September 30 at 12:00 CEST. You can register here.

The initial case is a PA chest radiograph of a 61-year-old man with hemoptysis.

Do you see any abnormality?
1. Yes
2. No
3. I want a lateral chest

Register for the webinar and lear more about this case and others!

Click here to see the answer

Findings: PA radiograph (A) does not show any significant findings. The lateral view shows a posterior pulmonary nodule with irregular contour (B, arrow). A typical donut sign is visible (B, circle), indicative of enlarged subcarinal lymph nodes.

Enhanced axial CT and PET-CT show confirm the pulmonary nodule (C-D, arrows) and the subcarinal lymphadenopathies (C-D, red arrows).

Final diagnosis:

Carcinoma hidden in the PA view behind the right hilum with metastases to subcarinal lymph nodes.
 
Congratulations to drpeca who was the first to want a lateral view.
 
Teaching point: remember that about 26% of the lung is hidden in the PA view. A lateral chest radiograph is indispensable to study the chest.

Cáceres’ Corner Case 243 – SOLVED

Dear Friends,

Today’s radiographs belong to a 59-year-old man with two week’s history of chest pain and moderate dyspnea.

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

Click here to see the answer

Findings: PA radiograph shows a diffuse opacity of left lung (A, asterisk) which obscures the heart border. A luftsichel sign is visible (A, circle). The left hilum is augmented, and the left main bronchus has a horizontal path (A, red arrow). The left hemidiaphragm is elevated and a juxtaphrenic peak sign is visible (A, yellow arrow).
The lateral view shows a horizontal retro-sternal band (B, arrows) and a typical donut sign (B, circle).

Donut sign is more obvious when comparing with a normal previous chest film
(C-D, circles).

This case is a compendium of typical signs of LUL collapse. As you all know, the most common cause is bronchogenic carcinoma, which in this case is confirmed by detecting enlarged mediastinal lymph nodes (donut sign).
Enhanced CT demonstrates the LUL collapse (E-F, asterisks), a mass occluding the bronchus (E-F, red arrows) and subcarinal adenopathy (E-F, arrows).

Final diagnosis: carcinoma of LUL bronchus with lobar collapse and mediastinal metastases.

Dr. Pepe’s Diploma Casebook 159 – SOLVED

Dear Friends,

Today I am presenting another “Art of interpretation” case. As I have mentioned before, interpreting a chest radiograph may be a difficult task and analyzing the diagnostic steps helps to a correct evaluation of the findings.

Radiographs belong to a 57-year-old woman with cough and pain in the chest.

Diagnosis:
1. Pulmonary mass
2. Mediastinal mass
3. Pleural mass
4. Any 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

PA radiograph shows an ill-defined right perihilar and upper lung opacity( A, asterisk). The right hemidiaphragm is elevated. There is an obvious elevation of the right hilum. (A, red arrow).

Lateral view shows a well-defined retro-sternal triangular opacity (B, white arrows) with a rounded convex appearance at the level of the hilum (B, red arrow).

Analysis of relevant findings:

PA chest

1. Elevation of right hilum
2. Hazy opacity in right upper lung
3. Elevated right hemidiaphragm

Lateral chest

1. Well-defined retro-sternal triangular opacity with a bulge in the middle

The clue to the diagnosis lies in discovering the elevation of the right hilum in the PA view. Neither a mediastinal nor a pleural mass should displace the hilum upwards. Therefore, the correct answer is: 1. Pulmonary mass.

The elevated right hilum suggests loss of volume of RUL, supported by the haziness of upper lung and elevation of the hemidiaphragm.

The lateral view provides significant information: the retro-sternal triangular opacity is highly suspicious of RUL collapse, limited superiorly by the displaced major fissure and inferiorly by the minor fissure. The central bulge suggests a mass as the cause of the collapse.

ELEVATED RIGHT HILUM + SIGNS OF RUL COLLAPSE (LATERAL VIEW) + HILAR MASS IN LATERAL VIEW = CARCINOMA WITH ATYPICAL RUL COLLAPSE

Enhanced coronal CT confirms the central mass (A, arrow) and the collapsed RUL (A, red arrow). Sagittal view shows the displaced major fissure (B, arrow). Axial view demonstrates the obstructed RUL bronchus (C, arrow)

Final diagnosis: Carcinoma of RUL bronchus with atypical collapse of RUL

Recognizing lobar collapses in the chest radiograph is important because most of them are caused by endobronchial carcinoma.
RUL collapse has a distinctive appearance which is easily identified in the PA radiograph (see Diploma 58). Occasionally the presentation is atypical and may be unrecognized, causing an unnecessary delay in the diagnosis. In these cases it is important to know the main signs that will suggest the correct diagnosis (see Diploma 141).
Elevation of the right hilum, as in the present case, is practically a constant sign in RUL collapse. Detecting a high hilum is an important clue to suspect this diagnosis.

To emphasize the importance of an elevated hilum as a sign of atypical RUL collapse, I am showing a second case. Patient is a 77 y.o. man with right shoulder pain.

PA radiograph shows an apparent air-filled cavity in the right upper lung. The clue to the diagnosis lies in recognizing the elevation of the right hilum (A, arrow), pointing to a RUL collapse.
Lateral view confirms the suspicion of RUL collapse confined between the elevated minor fissure (B, arrow) and the anteriorly displaced major fissure (B, red arrow).

Comparison with a previous film confirms the typical findings of aerated RUL collapse, with elevation of the minor fissure (C, arrow) and the right hilum (C, red arrow). The appearance of the current film is due to an apical loculated pneumothorax (D, asterisk) which has displaced medially the outer wall of the RUL lobe.

Previous CT taken three years earlier confirms collapse of RUL lobe with open bronchus (E, arrow), bronchiectasis in the lateral view and marked displacement of the fissures (F, arrows). Note the increased apical fat (E, asterisk) suggestive of a chronic process.

Final diagnosis: Chronic inflammatory collapse of RUL with loculated apical pneumothorax


Follow Dr. Pepe’s advice:

1. Detecting an elevated right hilum is an excellent clue to suspect an atypical presentation of RUL collapse

Cáceres’ Corner Case 242 – SOLVED

Dear friends, welcome back!

Today I am showing a straightforward case to ease you into the new season. Promise I will not mention Covid-19 at all.

Today’s case is a pre op PA radiograph for knee surgery in a 47-year-old woman.

What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Lung and mediastinum do not show any relevant findings. An isolated air-fluid level is visible in the left upper quadrant of the abdomen (A, arrow). The inner border of the cavity is smooth. The gastric bubble is visible under the left hemidiaphragm (A, red arrow).

Given that the patient is asymptomatic, an abdominal abscess or bowel obstruction/ volvulus can be safely excluded. A large intestinal diverticulum could be a possibility. I suspected a more mundane diagnosis: a review of the clinical history discovered that an intragastric balloon had been inserted fourteen months earlier.

Final diagnosis: air-fluid level in an intragastric balloon for morbid obesity
 
Congratulations to all of you who detected the air-fluid level. Kudos to Flemming Ghomsen who came close to the diagnosis.

Intragastric balloons for bariatric surgery may be filled with air or with saline. In the second case they may present an air-fluid level due to room air mixing during the injection of fluid.
 

Teaching points:


1. Remember to look under the diaphragm. You may discover interesting findings.
2. In your differential diagnosis always include iatrogenesis as a possible cause.

Dr. Pepe’s Diploma Casebook 158 – SOLVED

Dear Friends,

this is the last case of the first semester. Will meet again in September.
Wish all of you a very happy summer vacation!

This is a new “art of interpretation” case. Radiographs belong to a 40-year-old woman with mild cough.

What do you see?

Diagnosis:

1. Chronic TB changes
2. AV malformation
3. Bronchial atresia
4. Any of the above

Click here to see the answer

To refresh your memory, remember that interpreting a chest radiograph involves three basic steps:

1. Gather information. Examine the radiographs carefully and collect all the pertinent information. Remember that overlooking visible findings is the main cause of errors.

2. Analyze the findings. Once collected, the findings should be properly evaluated, and an opinion should be offered.

3. Decide on the next step to reach the diagnosis.

Step 1. Information:

In this patient the lateral view is unremarkable.
All relevant findings are seen in the PA radiograph:

1. Tubular branching opacities in the left upper lung (A, red arrows)
2. Increased lucency of left upper lung (A, circle)
3. Negative finding: the left hilum is in its normal position.

Step 2. Analysis of the findings:

1. Branching tubular opacities have a limited differential diagnosis: either they are pulmonary vessels or mucous-filled dilated bronchi.

2. Hyperlucent lung is a reliable sign of lung disease when complemented with an expiration film to demonstrate air-trapping.

3. The normal position of the left hilum is a negative finding that excludes a fibrotic process in the LUL (I.e. chronic TB), which should cause upper retraction of the hilum.

The combination of a lucent lung lesion with branching tubular opacities points towards an obstructive process of a segmental bronchus with mucous impaction (Obstruction of a lobar bronchus would cause lobar collapse instead of increased lucency).

TUBULAR BRANCHING OPACITIES + INCREASED LUNG LUCENCY = SEGMENTAL BRONCHIAL OBSTRUCTION

Step 3. Decide on the next step

Once segmental bronchial obstruction is suspected in the chest radiograph, the best procedure to confirm it is an enhanced chest CT with expiratory views. In this case it shows attenuated upper lobe vessels (B, arrows) and obvious mucous impactions (B-C, red arrows).
Axial CT with lung window confirms the increased lucency of the apical-posterior segment of the RUL (D, circle)

Inspiration/expiration axial CT views (E-F) confirm segmental air trapping on the left.

Bronchoscopy did not show any inflammatory or tumoral changes in the LUL bronchus. The orifice of the apical-posterior segment was missing.

Final diagnosis: bronchial atresia of apical-posterior segment of LUL

In my experience, bronchial atresia is the most common congenital lung malformation seen in adults. Congenital bronchial atresia results from proximal interruption of a segmental bronchus, which causes overinflation of the affected segment and secondary mucus impaction. Chest radiography shows a focal hyperlucent area with internal mucus impaction. CT depicts these findings to better advantage. Inspiration and expiration views help to confirm air-trapping. In case of doubt, bronchoscopy excludes other causes of bronchial obstruction.

Congenital bronchial atresia may present different appearances, as shown in the following case of one of our X-ray technicians.

30-year-old female, asymptomatic. PA chest radiograph (A) shows hyperlucent left lung with discrete dextroposition of the heart. Expiration film (B) shows air-trapping on the left with deviation of the mediastinum towards the right. Note a thick tubular shadow in the left lower lung (A-B, red arrows), compatible with bronchial impaction. The findings are suggestive of congenital bronchial atresia

Axial and coronal enhanced CT show increased lucency of the posterior segments of LLL with a central mucous impaction (C-D, red arrows)

Decreased vascularity of LLL and central mucous impaction (E-F, red arrows) are better demonstrated in the MIP reconstruction.

Coronal view eleven years later show that air is now present within the dilated bronchus, confirming the diagnosis (G-H, circles) .


Dr. Pepe’s teaching point:

Hyperlucent lung with mucous impaction are the hallmark of congenital bronchial atresia.

Cáceres’ Corner Case 241 – SOLVED

Dear Friends,

Today’s radiographs belong to a 24-year-old woman with cough and fever. What do you see?

More images will be shown next Wednesday and the answer will be published on Friday.

Click here to see Monday images


Dear Friends,

Showing today CT images of the chest. What do you think?

Click here to see the new images

Click here to see the answer

Findings: Chest radiographs show air-space disease in the right lower lobe (A-B, arrows). There is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.

Axial CT with lung window shows RLL air-space disease without cavitation (C, arrow). Mediastinal window at different levels confirms enlarged paratracheal, subcarinal and neck lymph nodes with hypodense center (D-F, red arrows). These findings should suggest active tuberculosis as the first possibility.
Although TB usually affects upper lobes, isolated involvement of lower lobes occurs in about 7% of cases.
 
Mycobacterium tuberculosis was found in the sputum.

Final diagnosis: active TB.
 
Congratulations to Archanareddyt who was the first to make the diagnosis.
 
 Teaching point: lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should be tuberculosis.

Dr. Pepe’s Diploma Casebook 157 – SOLVED

Dear Friends,

The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.

Diagnosis:

1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.

Final diagnosis: superimposed hair braid simulating pulmonary disease

The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.

I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:

1. Nipples and skin lesions
2. Hair and/or hair implements
3. Garments

Nipple Shadows

Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.

Fig. 1. 58-year-old man with typical bilateral nipple shadows (A, arrows), unchanged in comparison with a previous film (B, arrows). Nipples are well seen on axial CT in the same patient (C, arrows). Nowadays, patients may come with their own nipple markers! (D).

Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)

Fig 2. 61-year-old woman with left pleuritic chest pain. PA chest film shows a small amount of left pleural fluid (A, white arrow) and a nodule at the right costophrenic angle (A, red arrow). Visual inspection showed a large right nipple as the cause of the false nodule. Two weeks later, the pleural effusion has disappeared, and the nipple shadow is no longer seen (B).

Fig. 3. 54-year-old man with a renal tumor. PA film shows a nodule in the LLL (A, arrow) that simulates a nipple, even with a nipple marker (B, arrow). Axial CT shows a metastatic nodule in the LLL and a larger one in the RLL, not seen in the PA chest radiograph (insert, arrows).

Skin lesions

Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.

Fig. 5. Chest wart simulating a lung nodule in the PA film (A, arrow). Lateral film shows the wart in the skin of the anterior chest wall (B, arrow). The wart is higher in this view because the upheld arms elevate it.

Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).


Fig 6. 65-year-old woman with syncope. PA radiograph shows a rounded opacity in the right lung (A, arrow), suspected to be a pulmonary infiltrate. Axial CT (B) show normal lungs. The opacity is due to a superimposed right breast prosthesis (B-C, arrows).

Hair

In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).

In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.

Fig. 7. Braid simulating an apical pulmonary nodule (A-B, arrows). The rubber band (A-B, red arrows) suggests the correct diagnosis

Fig. 8. Loose hair simulating a linear infiltrate or fibrosis in the right apex (A, white arrow). Note the same appearance in the lower neck (A, red arrow). The apex looks normal after the hair is lifted (B). The opaque rounded opacity that looks like a hair clasp (A-B yellow arrow) is a cervical disk prosthesis.

Fig 9. Two patients with rubber bands at the end of a braid simulating pulmonary nodules (A-B, arrows). In both, the braids are visible in the neck (A-B, red arrows). Despite that, patient B was referred for a CT examination to evaluate a left lung nodule.

Fig. 10. 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.

Clothing artifacts

Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).

Fig. 11. 27-year-old woman with multiple miliary nodules in both lungs (A, circles). The opacities result from a jeweled panther on the shirt she was wearing (B).

Fig 12. 45-year-old woman with previous breast carcinoma. PA radiograph shows small nodules in lower lungs (A, circles). Lateral view proves that the nodules are in a blouse (B, arrow)

Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)

Fig 13. 29-year-old man with a barely visible non-displaced fracture of the left clavicle (A, arrow), well demonstrated in the 3-D CT reconstruction (B). Components of the support brace for the fracture simulate enlarged upper lobe vessels (A, red arrows).

To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)

Fig 14. Routine chest radiograph during the Covid-19 scare. Notice the wire in the face mask (A-B, arrows)


Follow Dr. Pepe’s advice:

1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.