Author: Dr. Pepe

Cáceres’ Corner Case 226 – SOLVED

~ Dr. Pepe ~ 12 Comments

Dear Friends,

Today’s radiographs belong to a 27-year-old woman who came for a routine check-up.

Most likely diagnosis:

1. Thymic tumor
2. Enlarged lymph nodes
3. Aortic arch malformation
4. None of the above

CT images will be shown next Wednesday.

Click here to see the first images

Dear Friends,

Today I am showing enhanced CT images of the mediastinum in the early (A-B) and late phases (C-E).
What do you think?

Click here to see more images

Click here to see the answer

Findings: PA chest radiograph shows a right upper mediastinal mass with undulated border (A, arrow). There is increased opacity of the anterior clear space in the lateral view (B, circle). In my opinion, the most likely diagnosis would be thymic tumor, although the undulated border favors enlarged lymph nodes.

Enhanced axial CTs in the arterial phase show an anterior mediastinal mass with minimal enhancement (C-D, arrows) and a vascular space in the center (C, yellow arrow).

Coronal and axial CTs in the late phase show partial washout of the vascular space (E, yellow arrow). The clue to the diagnosis lies in the presence of several punctate calcifications within the mass (F-G, red arrows) consistent with phleboliths, which are practically diagnostic of hemangioma. The central vascular space also supports the diagnosis.

The patient had been diagnosed of mediastinal hemangioma two years earlier and comparison with previous chest films and CTs did not show any change.
 
Final diagnosis: Mediastinal hemangioma
 
Congratulations to Naegleria and MK who gave similar diagnosis both at exactly 12:55 P.M.
 
Teaching point: This case is unusual (I have seen only two of them in the mediastinum) but can be easily diagnosed if phleboliths are present (and recognized). Early in my residency I learned that, when finding phleboliths within a mass, the diagnosis should be hemangioma until proven otherwise.
 
Ref. HP McAdams, ML Rosado de Christenson, CA Moran. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994; 193:399-402

Cáceres’ Corner Case 225 – SOLVED

~ Dr. Pepe ~ 4 Comments

Dear Friends,

Today’s radiographs belong to a 37-year-old man with moderate fever.
What do you think?

Come back on Friday to see the answer!

Click here to see the answer

Findings: Chest radiographs show an intrapulmonary rounded opacity with ill-defined borders in the left lung (A-B, arrows). In a patient with fever and no other significant symptoms, the most likely diagnosis should be rounded pneumonia, although I was somewhat concerned about the good definition of the lower contour in the lateral view (B, red arrows), which is unusual in pneumonia.

The patient improved with treatment and follow-up radiographs four weeks later show only minimal residual findings in the PA view (C, arrow).

Final diagnosis: rounded pneumonia simulating a pulmonary mass.

Congratulations to Ahmad, who was the first to give the correct diagnosis. Silver medal to Sara Mercado/span>, who arrived second three hours later.

Teaching point: remember that not all pulmonary nodules/masses are malignant. If you want to know more about them, look up Diploma #51 “Innocuous pulmonary nodules”

Cáceres’ Corner Case 224 – SOLVED

~ Dr. Pepe ~ 8 Comments

Dear Friends,

Due to the coronavirus scare, Dr Pepe and Miss Piggy have eloped to the Bahamas, leaving me alone in charge of the blog. Until his return in late March, I will present interesting cases in the Caceres’ Corner. I may even dare to present a Diploma case, although I am not as knowledgeable as Dr Pepe.

This week’s case is a preoperative PA radiograph of a 47-year-old woman.

Diagnosis:

1. Double aortic arch
2. Enlarged azygos vein
3. Mediastinal mass
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 shows a right mediastinal bump at the confluence between the trachea and the RUL bronchus (A, arrow). There is a curved mediastinal line below (A, red arrow) and an extra mediastinal line in the left lower mediastinal border (A, yellow arrow).

The combination of these findings strongly suggests increased circulation in the azygos system, with prominent azygos and hemiazygos veins. In an asymptomatic patient the most likely diagnosis is a congenital interruption of the IVC with azygos continuation.
A double aortic arch can be ruled out because the right component raises higher than the left, and in this case the opposite occurs.

Unenhanced coronal CT confirms the dilated azygos arch (B, arrow) and the dilated ascending azygos (B-C, red arrows) and hemiazygos (C, yellow arrow)

Final diagnosis: Congenital interruption of the IVC with azygos continuation.
 
Congratulations to Hazem who was the first to give the correct answer and to Krister who gave a nice and accurate description of the findings.
 
Teaching point: this case is a good example of non-significant findings secondary to a congenital malformation, as mentioned in webinar eight.

Cáceres’ Corner Case 223 – SOLVED

~ Dr. Pepe ~ 9 Comments

Today’s radiographs belong to a 77-year-old man with dyspnea.

Diagnosis:

1.  Allergic aspergillosis
2.  A-V malformations
3.  Chronic changes post-TB
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 radiographs shows elongated opacities apparently arising from the hila (A, arrows). The lack of branching goes against mucous impactions. The clue to the diagnosis lies in the calcified pleural plaque in the right hemidiaphragm (A, red arrow), which is a sign that strongly suggests asbestos exposure.
This diagnosis is corroborated by the lateral view, which shows calcified pleural plaques in the anterior clear space (B, red arrow).

Previous AP and oblique rib radiographs after chest trauma show the undulated calcified plaque in the right hemithorax (C-D, arrows).

Unenhanced coronal CT confirms the plaque in the right hemidiaphragm (E, arrow). Axial CTs demonstrate the anterior plaques (F-G, red arrows), as well as the unaffected lung (F).

Final diagnosis: calcified pleural plaques simulating pulmonary disease.
 
Congratulations to Phi Pham, who was the first to make the correct diagnosis.
 
Teaching point: Remember that superimposed opacities may simulate intrapulmonary pathology.

Dr. Pepe’s Diploma Casebook 154 – All you need to know to interpret a chest radiograph – Eighth Session – SOLVED

~ Dr. Pepe ~ 6 Comments

Dear Friends,

Showing today the leading case of webinar eight. Radiographs belong to 27-year-old with seminoma and pain in the anterior chest wall. What is your opinion about the  clavicular lesion?

1. Metastasis
2. Osteomyelitis
3. Benign bone lesion
4. Any of the above

Check out the last webinar form the series explaining in detail this case on our youtube channel and and catch up on previous ones on the EBR YouTube channel!

Click here to see the answer

Findings: the chest radiograph shows a lytic lesion in the proximal right clavicle (A-B, circles). It has a sclerotic border (A-B, red arrows), indicating a slow-growing process. This finding excludes options 1 and 2 and leaves option 3. Benign bone lesion as the correct diagnosis.

This lytic lesion correspond to a normal variant, called the rhomboid fossa. It represents the insertion site of the costoclavicular ligament( yellow), which extends from first rib (red) to the proximal clavicle (blue).
Is a normal variant and should not to be mistaken for an osteolytic lesion.

It occurs in 30% of males and 5% of females. It is more common in the young and becomes less visible with age.

Final diagnosis: rhomboid fossa of right clavicle

Congratulations to Faelivrin, who made the correct diagnosis

Teaching point: it is important to know the most common normal variants of the chest, to avoid confusing them with pathology.

Cáceres’ Corner Case 222 – SOLVED

~ Dr. Pepe ~ 5 Comments

Dear Friends,

Showing today preoperative radiographs of 57-year-old man with a torn knee cartilage. Sorry about the poor quality of the lateral view.
What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Findings: PA radiograph show widening of the right superior mediastinum (A, arrow), imprinting the tracheal wall (A, red arrow).
In the lateral view there is increased opacity of Raider triangle (B, circle) with slight bowing of the posterior tracheal wall (B, red arrow).

The main causes of occupation of Raider triangle are two: either esophageal disease or congenital malformation of the aortic arch. The last one is the most likely, given the findings in the PA view.
 
Enhanced CT confirms a right aortic arch (C-D, arrows), crossing behind the trachea (C-E, red arrows) and causing the opacity in Raider triangle.

Findings are better seen in the 3-D reconstruction (F).

Final diagnosis: right aortic arch
 
Congratulations to Jolanta who made the correct diagnosis (my initial impression in the plain film was double aortic arch, so I will award another prize to Faelivrin for being wrong with me).
 
Teaching point: this case does not look very exciting, but right aortic arch is very common, and it is important to avoid confusing it with a mediastinal mass.
 
If you want to know more about malformations of the aortic arch, look up the article by Hanneman, Newman and Chan: Congenital variants and anomalies of the aortic arch, RadioGraphics 2017; 37:32–51

Cáceres’ Corner Case 221 – SOLVED

~ Dr. Pepe ~ 20 Comments

Dear Friends,

Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.

PA chest radiograph was normal and radiographs of the dorsal spine were taken.

What do you see?

Come back on Friday to see the solution!

Click here to see the answer

Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).

The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.

Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.

Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
 
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
 
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.

Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.