Cáceres’ Corner Case 201 – SOLVED!

Dear Friends,

my good friend José Luis López Moreno gave me this case: preoperative chest radiographs for hand surgery in a 39-year-old woman.

What do you see?

Com back on Friday to see the answer!

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a rounded opacity in the periphery of the left lung
(A, arrow) that seems to be calcified. Cone down view shows a whorled pattern (B, arrow). A braid is visible in the left supraclavicular area (A, red arrow). Lateral view (not shown) is unremarkable.

Scout view of the CT does not show the apparent lung lesion, which is not visible in the axial view of the lung (D).
The technician that took the chest radiograph told us that the patient had a long braid with a rubber at the end.

Final diagnosis: hair braid simulating a lung nodule
 
Congratulations to MK who was the first to suggest the right diagnosis. Kudos for effort to Coffee.
 
I must confess that I was fooled when showed this case. Despite noticing the braid in the left supraclavicular area (A, red arrow) I failed to connect it to the apparent lung nodule. I suspected a skin artifact, without excluding an osteochondroma of rib or scapula.
 
Teaching point: after showing three braid artifacts in the blog (case 109, 172 and 191), I missed the fourth one.
Nobody is perfect!

Cáceres’ Corner Case 200 – SOLVED!

Dear Friends,

the first case of Caceres’ corner was published in September 23, 2011. Today, seven years later, we are proud to present case 200. It was not always easy, but it was always fun and worth it. Thank you for your continuous support.

Today’s case was diagnosed by my friend and co-worker Carles Vilá. The PA radiograph was taken as a pre-op exam for renal stones.
Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images

Dear Friends,

we saw a peripheral opacity in the lower left hemithorax and performed a CT, which showed unexpected findings.
What do you see?

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Click here to see the answer

Findings: PA radiograph shows a faint opacity in the periphery of the left lower hemithorax (A, circle). A CT was recommended.

Axial CT shows an unexpected irregular basal opacity (B, arrow). Caudal slices show several parietal nodules (C-D, arrows).

Coronal CT shows the large basal opacity (D, arrow), as well as the small parietal nodules (D-E, red arrows).

The clue to the diagnosis lies in a negative finding: absent spleen in the left upper quadrant of the abdomen (D-E, asterisks), suggesting that the chest opacities may represent accessory spleens.
The patient was interrogated and stated a previous car accident with ruptured spleen and subsequent splenectomy. A test with labelled erythrocytes in another institution confirmed the accessory spleens.
 
Final diagnosis: thoracic splenosis
 
As I am writing this (12:00 PM Thursday), nobody has suggested the right diagnosis. I was expecting many correct answers, since I showed a similar case eight weeks ago (Diploma case 135).
 
Teaching point: remember the importance of negative findings (Diploma cases 135 and 136). In this particular patient, they were crucial to suggest the correct diagnosis.

Congratulations to MK, who made a last-minute diagnosis at 2:08 P.M. on Thursday!

Cáceres Corner Case 199 – SOLVED!

Dear Friends,
Today´s case is provided by my good friend Alberto Villanueva.

PA radiograph belong to a 58-year-old man with cough and weight loss. Gastrectomy for stomach cancer in 2006. A previous film is shown for comparison.

Do you see any abnormality?

More images will be shown on Wednesday

Click here to see the images shown on Monday

Dear Friends,

showing a PA chest radiograph taken three months later.

What do you see?

Click here to see the new image

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Findings: PA radiograph taken in February 2018 shows an area of increased opacity in the subcarinal region (A, red arrows), more evident when compared with a previous film of 2014 (B). This finding was not detected.

Three months later the patient returned with increasing dyspnea. PA chest radiograph shows the typical appearance of RLL collapse, evidenced by a basal triangular shadow (C, arrow), downward hilar displacement (C, yellow arrow) and tracheal displacement. The subcarinal mass is now more evident (C, red arrow). Enhanced coronal CT shows the central mass (D, red arrows) as well as the RLL collapse (D, arrow).

Final diagnosis: oat-cell tumor of the lung

Congratulations to Elisa and Krister A, who were the first to detect the subcarinal mass in the initial examination
 
Teaching point: most of you detected the subcarinal mass that was missed in the original reading. This case emphasizes the importance of comparing with previous films to detect subtle findings.

Cáceres Corner Case 198 – SOLVED!

Dear Friends,

Today I’m presenting chest radiographs of a 28-year-old man with severe headache and high blood pressure (201/110 mmHg).

What do you see?

Click here to see the see the images


NEW CLINICAL INFORMATION:

Pulses were weaker in the lower extremities.

Click here to see the see the answer

Findings: Chest radiographs show a moderate cardiomegaly. There is pulmonary vascular redistribution, with the upper vessels (A, red circles) larger that the lower ones (A, blue circles), indicating an early stage of left cardiac failure.
The information of weak pulses in the lower extremities is important. This finding suggests impeded blood flow in the thoracic aorta, the most common cause being aortic coarctation. The small aortic knob and the lack of rib notching go against it, though.

CT angiogram shows narrowing and complete interruption of the distal thoracic aorta (C-E, circles), with abundant collateral circulation. The mid-aortic syndrome usually happens in children and young adults. The etiologies vary. In this particular case, biopsy confirmed Takayasu arteritis.

An aortic graft was placed to circumvent the obstruction (F-G, arrows).

Final diagnosis: Mid-aortic syndrome secondary to Takayasu arteritis
 
Congratulations to Ner, who made the correct diagnosis and to Krister A who was the first to suggest aortic obstruction.
 
Teaching point: in a young person with severe hypertension, distal pulses should be checked. If weak, aortic coarctation should be suspected. If the telltale signs of coarctation are missing, mid-aortic syndrome should be considered.

Cáceres’ Corner Case 197 – SOLVED!

Dear Friends;

Today I am showing a preoperative PA chest radiograph for knee surgery in a 50-year-old woman. More images will be shown on Wednesday.

What do you see?

Click here to see the images published on Monday


Dear Friends,

showing today axial CTs and a cone down view of lesion. Hope they clarify your thoughts.

Click here to see the new images

Click here to see the see the answer

Findings: PA chest radiograph shows a well-defined opacity in the apex of the right lung. There is pleural thickening in the periphery of the opacity (A, arrow) that suggests an extrapulmonary location. There is a chain-like line in the periphery, better seen in the cone down view (A-B, red arrows), which looks like metallic surgical sutures. In addition, an irregular mass is visible in the right upper mediastinum (A-B, yellow arrows).


Discovering metallic sutures raises the possibility of post-surgical changes. It was found that the patient had been treated five years earlier with bullectomy and talc pleurodesis for persistent pneumothorax (C-D, arrows).

Enhanced axial CT at the present time shows a cystic pleural collection surrounded by talc (E, arrow). A caudal paramediastinal clump of talc (F, arrow) explains the right mediastinal mass seen in the plain film.

Final diagnosis: post-operative changes after bullectomy and talc pleurodesis for persistent pneumothorax.
 
Congratulations to Ner, who gave an excellent discussion and discovered the metallic sutures in the plain film.
 
Teaching point: Remember to look carefully at the radiographs. A simple finding, such as discovering metallic sutures, may lead to the correct diagnosis before CT.

Cáceres’ Corner Case 196 – SOLUTIONS


Dear Friends,

Welcome to 2019! I will start the year with preoperative chest radiographs for meningioma in a 78-year-old woman.
More images will be shown on Wednesday.

What do you see?

Click here to see the images showed on Monday

Dear Friends,

Presenting CT images of the chest. Do they help?

Click here to see more images

Click here to see the solution

Findings: PA radiograph shows a bilobed lesion in the LLL (A, arrow) with ill-defined margins, which makes it intrapulmonary. It is rounded in the lateral view, with ill-defined inferior border (B, arrow).

Enhanced axial CT shows a pulmonary mass with little enhancement (C, arrow). Coronal and sagittal views show distal pulmonary impactions (D-E, arrows), suggesting an intrabronchial location.

Bronchoscopy confirmed an intrabronchial mass in the L10 segmental bronchus. Biopsy returned as atypical carcinoid.
 
Final diagnosis: atypical carcinoid with distal bronchial impaction
 
Congratulations to Ner, who made a good interpretation of the plain film and CT. And saw a finding that I overlooked: increased posterior lucency in the lateral view. I reviewed the original CT and the lucency was not evident, although an expiratory CT was not done.
 
Teaching point: this case complements nicely my recent webinar on endobronchial lesions. Remember that bronchial mucous impaction is an important sign to suspect malignant endobronchial tumors.