Cáceres’ Corner Case 206

Dear Friends,

Now that Game of Thrones is ending, a new series is planned: Game of Thorax, in which either you diagnose or you die.

As you can see in today’s radiograph, the Iron Throne has been replaced by the Chest Throne.

What would your diagnosis be?

Come back on Friday to see the answer.

Cáceres’ Corner Case 205

Dear Friends,

Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.

What do you see?

More images will be shown on Wednesday.

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Dear Friends,

showing today chest radiographs taken one year earlier.

Do they help?

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Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).

Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).

The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.

CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).

Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).

The patient was found to have a history of asbestos exposure.
 
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.

Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
 
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!

Cáceres’ Corner Case 204 – SOLVED

Dear Friends,

Today’s radiographs belong to a 54-year-old man with chest pain.

More images will be shown on Wednesday.

What do you see?

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Dear Friends,

Showing new images of the thoracic cage. 

What do you think?

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Click here to see the answer

Findings: PA radiograph shows an extrapulmonary lesion in the left hemithorax (A, arrow). The 3rd left rib is broadened (A, red arrows) and the distal segment is not visible.
There is a lineal infiltrate in the adjacent lung and at the left lung base. In addition, an expansive lytic lesion is visible in the anterior 7th right rib (A, yellow arrow).
The lateral view (B) does not show any significant findings.

AP and oblique views of the thoracic cage show an expansive lesion of the 3rd left rib (C-E, arrows) and confirm the expansive lytic lesion of the right 7th rib (C-E, red arrows). There is also a pure lytic lesion of the 8th left rib (C-E, red circle). There is minimal loss of height of D-11 (C and E, blue circle).

Discovering expanding lesion of the ribs should suggest either multiple myeloma or metastases (renal cell carcinoma, thyroid carcinoma). In this patient a multiple myeloma was found.
 
Final diagnosis: multiple myeloma, IgA type.
 
Congratulations to VL who found the bone lesions in the initial radiographs (many of you ignored satisfaction of search) and to archana reddy.t, who made the final diagnosis.
 
Teaching point: remember to look at the underlying rib in any extrapulmonary lesion. Discovering rib involvement focus your diagnostic approach and limits the differential diagnosis.

Cáceres’ Corner Case 203 – SOLVED!

Dear Friends,

Today I am showing radiographs of a 40-year-old man with chest pain.
What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today enhanced CT images of the case.

Do they help?

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Findings: PA radiograph shows a mediastinal mass (A, arrow) superimposed to the right hilum. In the lateral view the mass is faintly visible behind the distal trachea (B, circle). This location excludes a right hilar mass, because the right hilum is anterior to the trachea.

Enhanced coronal and sagittal CT confirm a posterior mediastinal mass (C-D, arrows) with necrotic areas and marked contrast enhancement. This is an important finding because it limits the differential diagnosis to four conditions: intrathoracic goiter, Castleman’s disease, paraganglioma and hemangioma.
Some of you have mentioned extramedullary hematopoiesis. In my (limited) experience I don’t recall seeing avid contrast enhancement in it. I have asked some friends and searched the web without finding a clear answer. If any of you have better information I am willing to be corrected. At any rate, this patient does not have any bone abnormalities, which makes the diagnosis of extrapulmonary hematopoiesis very unlikely.
 
Final diagnosis: posterior mediastinal paraganglioma surgically proved. A similar case was presented in case 168 of Caceres’ corner.
 
Congratulations to MK, who was the first to suggest the correct diagnosis.
 
Teaching point: remember the four mediastinal processes with avid contrast enhancement: intrathoracic goiter (frequent), Castleman´s disease and paraganglioma (uncommon) and hemangioma (never saw a case).

Cáceres’ Corner Case 202 – SOLVED!

Dear Friends,

Dr. Pepe is busy preparing next week’s webinar (click here to register!) and asked me to present a case this week. The case is provided by my friend Jordi Andreu.

Radiograph belong to  a 83-year-old woman with dementia. A mass was detected in the right lung and a CT was done.

What do you think?

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Findings: AP chest radiograph shows a well-defined opacity in the right upper hemithorax (A, arrow) which appears to be extrapulmonary. There are calcified granulomas in the left apex with retraction of the left hilum.

Unenhanced axial and coronal CT show an extrapulmonary mass with a calcified rim (B-C, arrows). The mass has a striated appearance, alternating lineal areas of different opacities. This CT appearance is practically pathognomonic of oleothorax (see case 19 of Caceres’ corner).

Instillation of oil in the extrapleural space (oleothorax, plombage) was used to collapse the lungs facilitating healing of TB cavities. It was abandoned in the early fifties after the discovery of effective antimicrobial therapy.
The patient had pulmonary TB in her youth and told us that it was treated by instillation of a substance. A clinical photograph in another patient (D) documents the surgical scar.

Final diagnosis: Oleothorax
 
Congratulations to Diogo, who was the first to make the diagnosis and to Jake, who concurred two days later.
 
Teaching point: this is an uncommon pathology, but it should be known because the appearance is pathognomonic and shouldn´t be confused with other conditions. This patient was seen four weeks ago and diagnosed initially of pleural tumour.

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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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!