Cáceres’ Corner Case 256 – SOLVED

Dear Friends,

welcome to the second trimester of 2021! Showing today PA chest radiograph of a 66-year-old man with chest pain without any other symptoms.

What do you see?
More images will be shown on Tuesday and Wednesday.

Dear friends, showing today the lateral chest view.
Does it help?

Today I am showing an enhanced axial CT.
What would be your diagnosis?

Click here to see the answer

Findings: PA chest radiograph shows an increase in size and opacity of the left hilum
(A, arrow), due to superimposition of a well-defined posterior mass visible in the lateral view (B, arrow). At first glance, the appearance of the mass is compatible with an extrapulmonary lesion. However, there is retrocardiac nodule in the PA view (A, red arrow), suggesting a metastasis from an intrapulmonary mass.

Enhanced axial CT confirms an irregular pulmonary mass (C, arrow), which is invading the chest wall, as confirmed by the displaced intercostal artery (C, yellow arrow) and erosion of the underlying rib (D, circle).

Caudal slices confirm the retrocardiac nodule (E, white arrow) and additional nodules (E-F, red arrows) representing pleural implants.
Biopsy of the main mass returned as lung carcinoma.

Final diagnosis: Carcinoma of the lung simulating an enlarged hilum in the PA view.
 
Congratulations to Dr LeLam and thaf1212, who detected the retrocardiac nodule, which is the clue to determine that the main mass is intrapulmonary.
 
Teaching point: Remember that one of the three causes of unilateral enlarged hilum is superposition of a pulmonary opacity either in front or behind the hilum (the other two are enlarged hilar lymph nodes and increase in size of the pulmonary artery)

Cáceres’ Corner Case 255

Dear friends,

today I am presenting preoperative chest radiographs for knee surgery in a 47-year-old woman.

More images will be shown on Wednesday.

What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA chest radiograph shows a bump in the left hemidiaphragm (A, arrow). It is partially hidden in the lateral view by the shadow of the right hemidiaphragm and the cardiac silhouette (B, arrows).

Diaphragmatic bumps are common on the right and rarer on the left, especially in young persons. I was curious about this finding and reviewed an abdominal CT done a few weeks earlier. Enhanced axial, coronal and sagittal images demonstrate an intact diaphragm and a fluid-filled structure in the thoracic side (C-E, arrows). The appearance is typical of a diaphragmatic cyst.
 
Diaphragmatic cyst is a congenital lesion, asymptomatic and absolutely harmless. It is easy to demonstrate with CT and should not be removed. They are rare (I have seen only four during my professional life). I thought it interesting to acquaint you with this rare entity.

Final diagnosis: congenital diaphragmatic cyst
 
Teaching point: not all diaphragmatic bumps are hernias or eventrations. When they occur in the left side in a young person, consider other possibilities, such as a congenital cyst or a fibrous pleural tumor.

Cáceres’ Corner Case 254 – SOLVED

Dear Friends,

today’s radiographs belong to a 34-year-old woman with moderate cough. Previous history of asthma.

What do you see?

Diagnosis:

1. Mucous plug
2. Segmental atelectasis
3. Tuberculosis
4. None of the above

Click here to see the answer

Findings: Pa chest radiograph shows a tubular opacity that seems to arise from the right hilum (A, arrow). The lateral chest (B) does not show any abnormality, which raises the possibility that the opacity in the PA view is spurious.

Careful inspection demonstrates that the opacity extends to the right apex and to the neck (C, red arrows). The appearance is typical of a superimposed pigtail.

Some of you described the slightly elevated minor fissure. It is an unfortunate coincidence, probably related to previous episodes of mucous plug in an asthmatic patient causing mild loss of volume of RUL.
 
Final diagnosis: Pigtail simulating pulmonary disease.
 
Congratulations to MK who was the only one to suggest the correct diagnosis.
 
Teaching point: You may think that I tricked you, but it was not my intention. This case is a reminder that apparent pulmonary opacities may be located in the pleura, chest wall or outside of the body.
 
To emphasize this point I am showing two more cases of braids simulating pulmonary disease, presented in earlier blogs.

CASE 1. 48-year-old woman with mild cough. PA radiograph shows an ill-defined opacity in the left lung, running from top to bottom (A, white arrows). The opacity extends towards the neck (A, red arrow), which suggests that it is external to the lung. Lateral view shows an elongated opacity in the back of the chest (B, arrows).

A photo of the patient (C) confirms that a long braid is the cause of the opacity. PA radiograph after lifting the braid demonstrates that the chest is normal (D).

CASE 2. 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.

Cáceres’ Corner Case 253 – SOLVED

Dear Friends,

Today’s case is a PA chest radiograph for knee surgery in a 28-year-old man.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows an osteochondroma in the right humerus (A, yellow arrow). There are two more in the anterior arch of the left fifth rib and in the proximal end of the right clavicle (A, red arrows).
They are better seen in the cone down views (B-D, arrows).

The first and only diagnosis that comes to mind is multiple osteochondromatosis, confirmed with views of the lower extremities (E-G).

Final diagnosis: Multiple osteochondromatosis.
 
Most of you did very well in this case. Congratulations to Mauro, who was the first and to Kaushalya and Ali who made back-to-back diagnosis in a five-minute interval.
 
Teaching point: remember to look at the bones of the chest, especially when taking an examination. It may surprise the examiner and win you a few extra points.

Cáceres’ Corner Case 252 – SOLVED

Dear Friends,

Since this week is my birthday, I am showing a simple case. Chest radiographs were taken in a routine study for asbestos exposure in a 42-year-old man.

Will show more images on Wednesday.

Click here to see the images shown on Monday


Dear Friends,

showing today a cone down view of the lateral chest. What does the pattern suggest?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows punctate opacities in the upper and middle thirds of the right lung. The right heart border is indistinct (A, circle) suggesting RML disease.

The lateral view confirms RML disease (B, circle). A cone down view demonstrates thick lineal branching lines (C, circle) highly suspicious of dilated mucous-filled bronchi.
(Branching structures in chest radiograph are either vessels or mucous -filled bronchi).

Unenhanced sagittal and axial CTs show bronchiectasis of RML and lingula (D-E, circles).

Final diagnosis: RML bronchiectasis detected in the lateral view of the chest
 
Congratulations to MK, who made the diagnosis.
 
Teaching point: I presented this case because it is a nice example of bronchiectasis with mucous impaction suspected in the plain film. I posted it on Monday without having seen the CT because whoever read it told me that bronchiectasis were present.
I reviewed the CT two days ago and was surprised to discover two vital findings
that I had not been told:
 
1. The CT showed centrilobular and tree-in-bud opacities (F-G, circles), typical signs of bronchiolitis.
2. These findings plus RML and lingular bronchiectasis are a classic presentation of atypical mycobacterial infection.

So, what started as an unsuspected discovery in the plain film ended up with the serendipitous diagnosis of atypical mycobacterial infection (unproven, but likely). The attending physician has been notified and when a germ is found I would let you know

Cáceres’ Corner Case 251 – SOLVED

Dear Friends,

Showing today radiographs of a 27-year-old man with fever and hemoptysis.
More images will be shown on Wednesday

What do you see?

Click here to see Monday images


Dear friends, attaching CT images of the chest and abdomen. Do they help?

Click here to see more images

Click here to see the answer

Findings: chest radiographs show a cavitated pulmonary lesion in the apical-posterior segment of the LUL (A-B, arrows). There is convexity of the left middle mediastinum
(A, red arrow).

Enhanced axial CTs show an irregular pulmonary mass with cavitations (C-D, arrows). The thymus is enlarged, with a central area of decreased density (D, red arrow).

Enhanced axial abdominal CTs demonstrate enlarged retroperitoneal lymph nodes
(E-F, circles) as well as enlarged mesenteric lymph nodes (E, red ellipse).

In summary, the findings are:
 
Cavitated lung mass. Etiology: TB, fungal infection, lymphoma, Wegener and other granulomatosis.
Enlarged thymus. Etiology: thymoma, germ-cell tumor, thymic lymphoma
Enlarged retroperitoneal and mesenteric lymph nodes. In my opinion, this is a crucial finding, because it is highly suspicious of lymphoproliferative disease.
 
Putting all the findings together, lymphoma is the most likely diagnosis.
In this patient the initial diagnosis was TB. No TB germs were grown from the bronchial aspirate and PPD was negative. Abdominal CT seven days after admission suggested the diagnosis of lymphoma, confirmed by biopsy, which demonstrated widespread Hodgkin disease, nodular sclerosis type.
 
Final diagnosis: Cavitated Hodgkin disease of the lung.

Congratulations to all of you who made a gallant effort to diagnose the case. Will single out Olena because she was the first to mention lymphoma.
 
Teaching point: As this case proves, cavitated lesions of the lung are difficult to diagnose by chest imaging alone. Sometimes you need all the help you can get.

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.

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!

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

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