Cáceres’ Corner Case 214 – SOLVED

Dear Friends,

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

Diagnosis:

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

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

Click here to see the answer

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

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

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

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

Cáceres’ Corner Case 213 – SOLVED

Dear Friends,

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

What do you see?

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

Click here to see the answer!

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

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

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

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

Cáceres’ Corner Case 212 – SOLVED

Dear Friends,

Today’s radiographs belong to a 53-year-old man with dysphagia. 

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

Click here to see the solution

Findings: PA radiograph (A) is unremarkable. The lateral view shows a slight anterior bowing of the trachea (B, arrow) with an apparently dilated upper esophagus with an air/solid interface (B, red arrow).

These findings are well seen in the cone down view, which better shows a thickened retrotracheal stripe (C, red arrows), a sign that suggests esophageal pathology, among others.
For all of you who diagnosed achalasia there is a negative finding: the lack of occupation of the retrocardiac space (D, circle) which practically rules out dilatation of the lower esophagus.

Sorry to say that I do not have additional images. After receiving the possible diagnosis of esophageal tumor, the patient went to another hospital, where esophagoscopy and biopsy confirmed upper esophageal dilatation by a carcinoma of the middle third.
 
Final diagnosis: Carcinoma of the middle third of the esophagus with proximal dilatation and food retention.
 
Congratulations to Dr Ahmad who was the first to describe the findings.
 
Teaching point: this case emphasizes the value of clinical information in selected cases. I suspect that some of you would not have discovered the dilated esophagus in the lateral view if I had withheld the history of dysphagia :).

Cáceres’ Corner Case 211 – SOLVED

Dear Friends,

Today I’m showing chest radiographs of a 50-year-old woman with cough and sputum production.

What do you see?

You will have more images on Wednesday.

Dear Friends,

showing today CT images of the patient. What do you see?

Click here to see the CT images

Click here to see the answer

Findings: PA chest shows a small right lung, with a triangular opacity occupying the lower lung (A, arrow). The right heart border is not seen. The trachea and mediastinum are displaced to the right. In the lateral view the lower opacity occupies the lower lung from front to back (B, arrows).
This appearance is typical of combined RLL and RML collapse (obliteration of right heart border) and the most likely diagnosis is an obstructing lesion in the intermediary bronchus.

Enhanced axial CT shows marked narrowing of the intermediary bronchus (C, arrow). A caudal image shows marked dilatation of mucous-filled bronchi (D, arrows). This appearance indicates a long-standing obstruction and goes against a malignant process

Comparison with a previous radiograph (F) shows that the chest has not changed in comparison with the recent one (E). Bronchoscopy performed three years earlier demonstrated chronic stenosis of intermediate bronchus secondary to previous TB

Final diagnosis: Chronic TB changes of intermediary bronchus causing collapse of RML and RLL.
 
Congratulations to Maged Shaban and Yelgha who made the correct diagnosis of RLL and RML collapse
 
Teaching point: remember that central lobar collapse with bronchiectasis is rarely caused by malignancy.

Cáceres’ Corner Case 210 – SOLVED

Dear Friends,

showing another case seen during this summer. Preoperative chest radiography for knee surgery in a 57-year-old man. More images will be shown on Wednesday.

What do you see?

New images are shown:

Click here to see more images

Click here to see the answer

Findings: PA radiographs shows a right mediastinal mass at the level of the tracheal bifurcation (A, arrow), which has not changed significantly in comparison with a chest film taken for pneumonia one year earlier (B, arrow).

Several of you have mentioned a triangular shadow at the right cardiophrenic angle
(A-B, red arrows). This appearance should suggest paracardial fat pad as the first choice.

The differential diagnosis of a right mediastinal mass at the level of the tracheal bifurcation is simple: most of the times it is either an enlarged azygos vein or lymphadenopathy.
 CT shows a dilated azygos vein with a prominent azygos arch (C-D, arrows), suggesting a impeded blood flood either in the inferior or superior vena cava. Considering that the patient is asymptomatic, the most likely diagnosis is congenital interruption of the inferior vena cava, with azygos continuation. The diagnosis is confirmed noting the absence of the suprarenal portion of the IVC (C, circle) and the association of other congenital anomalies, such as polisplenia (C, red arrows) and abnormal bifurcation of the bronchial tree (E, arrows).

Coronal CT confirms that the triangular paracardial shadow represents paracardiac fat.

Final diagnosis: Congenital absence of IVC with azygos continuation
 
Congratulations to MK, who made a late (and accurate) diagnosis of prominent azygos vein
 
Teaching point: remember that the most common right lower paratracheal masses are either an enlarged azygos vein or mediastinal lymph nodes.

Cáceres’ Corner Case 209 – SOLVED

Dear Friends,

welcome to the next season of the blog!

During September I will show cases that I have seen this summer. Today’s radiograph belong to a 23-year-old woman who couldn’t elevate her left arm more than twenty degrees.

What do you see?

Come back on Friday to see the answer!

Click here to see the answer

 
Findings: AP radiograph of the left shoulder shows numerous rounded calcifications projected over the scapula and humeral head (A, circle). The first diagnosis that comes to mind is osteopoikilosis but, given the patient’s symptoms, chondromatosis of the shoulder should be considered.

The dilemma is easily solved by taking a comparison view of the contralateral shoulder, which shows identical findings (B and C, circles).

The patient’s mother was a physician and very anxious. She insisted in taking a radiograph of the pelvis, which again shows the typical findings of osteopoikilosis
(D, circles).

Final diagnosis: unsuspected osteopoikilosis
 
Congratulations to Zehra who was the first to suggest the correct diagnosis.
 
Teaching point: remember the usefulness of comparison films in MSK imaging

P. S. This a warm-up case to facilitate your return to the Diploma cases. Next week will be more difficult!

Cáceres’ Corner Case 208 – SOLVED!

Dear Friends,

Presenting today radiographs of a 65-year-old man with back pain.

What do you see?

Click here to see the images


Click here to see the answer

Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.

A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).

I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).

In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
 
Final diagnosis: Carcinoma of esophagus with bone metastases

Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.

Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!