Dr. Pepe’s Diploma Casebook 158 – SOLVED

Dear Friends,

this is the last case of the first semester. Will meet again in September.
Wish all of you a very happy summer vacation!

This is a new “art of interpretation” case. Radiographs belong to a 40-year-old woman with mild cough.

What do you see?


1. Chronic TB changes
2. AV malformation
3. Bronchial atresia
4. Any of the above

Click here to see the answer

To refresh your memory, remember that interpreting a chest radiograph involves three basic steps:

1. Gather information. Examine the radiographs carefully and collect all the pertinent information. Remember that overlooking visible findings is the main cause of errors.

2. Analyze the findings. Once collected, the findings should be properly evaluated, and an opinion should be offered.

3. Decide on the next step to reach the diagnosis.

Step 1. Information:

In this patient the lateral view is unremarkable.
All relevant findings are seen in the PA radiograph:

1. Tubular branching opacities in the left upper lung (A, red arrows)
2. Increased lucency of left upper lung (A, circle)
3. Negative finding: the left hilum is in its normal position.

Step 2. Analysis of the findings:

1. Branching tubular opacities have a limited differential diagnosis: either they are pulmonary vessels or mucous-filled dilated bronchi.

2. Hyperlucent lung is a reliable sign of lung disease when complemented with an expiration film to demonstrate air-trapping.

3. The normal position of the left hilum is a negative finding that excludes a fibrotic process in the LUL (I.e. chronic TB), which should cause upper retraction of the hilum.

The combination of a lucent lung lesion with branching tubular opacities points towards an obstructive process of a segmental bronchus with mucous impaction (Obstruction of a lobar bronchus would cause lobar collapse instead of increased lucency).


Step 3. Decide on the next step

Once segmental bronchial obstruction is suspected in the chest radiograph, the best procedure to confirm it is an enhanced chest CT with expiratory views. In this case it shows attenuated upper lobe vessels (B, arrows) and obvious mucous impactions (B-C, red arrows).
Axial CT with lung window confirms the increased lucency of the apical-posterior segment of the RUL (D, circle)

Inspiration/expiration axial CT views (E-F) confirm segmental air trapping on the left.

Bronchoscopy did not show any inflammatory or tumoral changes in the LUL bronchus. The orifice of the apical-posterior segment was missing.

Final diagnosis: bronchial atresia of apical-posterior segment of LUL

In my experience, bronchial atresia is the most common congenital lung malformation seen in adults. Congenital bronchial atresia results from proximal interruption of a segmental bronchus, which causes overinflation of the affected segment and secondary mucus impaction. Chest radiography shows a focal hyperlucent area with internal mucus impaction. CT depicts these findings to better advantage. Inspiration and expiration views help to confirm air-trapping. In case of doubt, bronchoscopy excludes other causes of bronchial obstruction.

Congenital bronchial atresia may present different appearances, as shown in the following case of one of our X-ray technicians.

30-year-old female, asymptomatic. PA chest radiograph (A) shows hyperlucent left lung with discrete dextroposition of the heart. Expiration film (B) shows air-trapping on the left with deviation of the mediastinum towards the right. Note a thick tubular shadow in the left lower lung (A-B, red arrows), compatible with bronchial impaction. The findings are suggestive of congenital bronchial atresia

Axial and coronal enhanced CT show increased lucency of the posterior segments of LLL with a central mucous impaction (C-D, red arrows)

Decreased vascularity of LLL and central mucous impaction (E-F, red arrows) are better demonstrated in the MIP reconstruction.

Coronal view eleven years later show that air is now present within the dilated bronchus, confirming the diagnosis (G-H, circles) .

Dr. Pepe’s teaching point:

Hyperlucent lung with mucous impaction are the hallmark of congenital bronchial atresia.

Dr. Pepe’s Diploma Casebook 157 – SOLVED

Dear Friends,

The leading case of this week’s Diploma has been provided by my good friend Jordi Andreu. Radiographs belong to an asymptomatic 48-year-old woman.


1. Neurogenic tumor
2. Pulmonary hamartoma
3. Pleural fibrous tumor
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows a rounded opacity in the left apex (A, arrow). All diagnosis are possible, as the pulmonary apex is a narrow space and it is very difficult to determine the origin of a mass. The clue lies in the nodular opacities in the neck (A, circle) which raise the possibility of superimposed hair braid.
Unenhanced coronal CT (B) does not show any mass, confirming that the finding is artifactual.

Final diagnosis: superimposed hair braid simulating pulmonary disease

The purpose of this presentation is to discuss elements in or about the soft tissues of the chest wall that may simulate lung disease. Those related to the thoracic skeleton were shown in Diploma case # 57.
This Diploma complements the non-significant findings described in webinar eight.

I have classified them into three groups, the first one related to the soft tissues of the chest wall while the other two are external to the body:

1. Nipples and skin lesions
2. Hair and/or hair implements
3. Garments

Nipple Shadows

Nipple shadows are seen in 3% to 10% of PA chest radiographs. In about 10% of these patients, the identification may raise doubts. Comparison with previous films will confirm the stability of the nodules (Fig. 1). In case of doubt, nipple markers should be placed. Routine use of nipple markers has been proposed in oncologic patients.

Fig. 1. 58-year-old man with typical bilateral nipple shadows (A, arrows), unchanged in comparison with a previous film (B, arrows). Nipples are well seen on axial CT in the same patient (C, arrows). Nowadays, patients may come with their own nipple markers! (D).

Unilateral enlarged nipple shadows are suspicious findings. Visual inspection should be done to confirm that the nipple is indeed enlarged (Fig. 2). Occasionally, a true lung nodule may simulate a nipple shadow, even with nipple markers. In such cases, CT will correct our error (Figs. 3-4)

Fig 2. 61-year-old woman with left pleuritic chest pain. PA chest film shows a small amount of left pleural fluid (A, white arrow) and a nodule at the right costophrenic angle (A, red arrow). Visual inspection showed a large right nipple as the cause of the false nodule. Two weeks later, the pleural effusion has disappeared, and the nipple shadow is no longer seen (B).

Fig. 3. 54-year-old man with a renal tumor. PA film shows a nodule in the LLL (A, arrow) that simulates a nipple, even with a nipple marker (B, arrow). Axial CT shows a metastatic nodule in the LLL and a larger one in the RLL, not seen in the PA chest radiograph (insert, arrows).

Skin lesions

Skin lesions may also cause false lung nodules. Visual inspection of the chest will demonstrate them and confirm the diagnosis (Fig. 5). If there is any doubt, a marker can be used.

Fig. 5. Chest wart simulating a lung nodule in the PA film (A, arrow). Lateral film shows the wart in the skin of the anterior chest wall (B, arrow). The wart is higher in this view because the upheld arms elevate it.

Occasionally, a discrepancy in density between both breasts, usually related to previous surgery, may simulate pulmonary pathology (Fig 6).

Fig 6. 65-year-old woman with syncope. PA radiograph shows a rounded opacity in the right lung (A, arrow), suspected to be a pulmonary infiltrate. Axial CT (B) show normal lungs. The opacity is due to a superimposed right breast prosthesis (B-C, arrows).


In my experience, hair is a common cause of opacities in the lung apices (Fig 7).
Strands of loose hair may project over the upper lung, simulating linear fibrotic infiltrates (Fig 8). Rubber bands at the end of braids may be confused with pulmonary nodules (Fig. 9). A long braid may fool us and consider it intrapulmonary disease (Fig 10).

In most cases, the clue to the diagnosis lies in recognizing that the abnormality extends to the neck.

Fig. 7. Braid simulating an apical pulmonary nodule (A-B, arrows). The rubber band (A-B, red arrows) suggests the correct diagnosis

Fig. 8. Loose hair simulating a linear infiltrate or fibrosis in the right apex (A, white arrow). Note the same appearance in the lower neck (A, red arrow). The apex looks normal after the hair is lifted (B). The opaque rounded opacity that looks like a hair clasp (A-B yellow arrow) is a cervical disk prosthesis.

Fig 9. Two patients with rubber bands at the end of a braid simulating pulmonary nodules (A-B, arrows). In both, the braids are visible in the neck (A-B, red arrows). Despite that, patient B was referred for a CT examination to evaluate a left lung nodule.

Fig. 10. 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.

Clothing artifacts

Clothing artifacts occur when the technician does not ask patients to remove garments that have logos or images on them. This usually happens with women, out of respect for modesty (Figs. 11 and 12).

Fig. 11. 27-year-old woman with multiple miliary nodules in both lungs (A, circles). The opacities result from a jeweled panther on the shirt she was wearing (B).

Fig 12. 45-year-old woman with previous breast carcinoma. PA radiograph shows small nodules in lower lungs (A, circles). Lateral view proves that the nodules are in a blouse (B, arrow)

Other types of body artifacts may cause dubious opacities in the chest radiograph (Figs 13 and 14)

Fig 13. 29-year-old man with a barely visible non-displaced fracture of the left clavicle (A, arrow), well demonstrated in the 3-D CT reconstruction (B). Components of the support brace for the fracture simulate enlarged upper lobe vessels (A, red arrows).

To end the presentation, in the last two months we have been acquainted with a new artifact: the wire in the face masks (Fig 14)

Fig 14. Routine chest radiograph during the Covid-19 scare. Notice the wire in the face mask (A-B, arrows)

Follow Dr. Pepe’s advice:

1. Unilateral nipple shadows may generate diagnostic problems.
2. If a hair artifact is suspected, look at the soft tissues of the neck.
3. Garments may create weird lung shadows.

Dr. Pepe’s Diploma Casebook 156

Dear Friends,

In the aftermath of the Covid-19 scare, I have elected to show a new  “Meet the Examiner” presentation, with questions and answers similar to a real examination. You will get the final answer at the end of the presentation.

Take your time before seeking the answer.

This case starts with PA and lateral chest radiographs of a 63-year-old man with acute chest pain. Would you suspect pulmonary embolism?

3.Need a CT

Click here to see the answer

Findings: the most significant finding is a broad right descending pulmonary artery (A, arrow) with an abrupt cut-off (A, red arrow), a sign of embolus in the artery (Palla sign). Oligemia of the right lung is also visible (Westermark sign). Both signs are suggestive of pulmonary embolism, to be confirmed with enhanced CT.
An enlarged azygos vein is also seen (A, yellow arrow), as well as a bump in the para-aortic line (A, blue arrow)

Click here to see more images

Enhanced CT confirms multiple pulmonary emboli (C, arrows) as well as a large embolus in the right descending pulmonary artery responsible for the Palla sign (D, red arrow)

Caudal slices show a non-enhancing opacity in the lower mediastinum. What would be the most likely diagnosis?

1- Lymphangioma
2- Varices
3- Neurofibromatosis
4- Any of the above

Click here to see the answer

Findings: the serpiginous appearance of the opacity (E-F, red arrows) is compatible with all three diagnosis. Mediastinal varices are the most likely diagnosis because they are not unusual, and the top of the spleen appears to be enlarged (F, asterisk).
The varices are not opacified because the images were taken during the arterial phase.

Late images taken during the venous phase show enhancement of the varices (G, arrow). Coronal reconstruction confirms the splenomegaly and a whorl of varices (H, arrow) responsible for the bump of the para-aortic line in the PA radiograph. The varices (V) drain into an enlarged azygos vein (I, arrow). The increased flow explains the prominent azygos in the PA chest film.
Review of the clinical history discovered that the patient had cirrhosis of the liver.

Final diagnosis: mediastinal varices in a patient with liver cirrhosis and pulmonary embolism

Paraesophageal varices are not uncommon and are secondary to portal hypertension in patients with hepatic cirrhosis. When enlarged, they are visible as a lower middle mediastinal mass in about 8% of chest radiographs of cirrhotic patients.
They may be misdiagnosed in CT studies because they don´t enhance in the arterial phase, as happened in the case presented and in a second case shown below.

Click here to see the second case

58-year-old man with liver cirrhosis. PA radiograph shows widening of lower mediastinal lines, which are slightly undulated (A, arrows). There is increased opacity of the left upper quadrant of the abdomen and the lateral wall of the stomach is indented, suggesting splenomegaly. On the lateral view there is increased opacity of the middle lower mediastinum, with a suggestion of tubular structures (B, circle).

Enhanced axial CT (arterial phase) shows a non-enhancing mass in the middle mediastinum that looks like a cyst (C, arrows). Venous phase demonstrates multiple enhanced veins within the mass (D, arrows). The cirrhotic liver and the enlarged spleen are visible in the coronal CT (E) .

Dr. Pepe’s teaching points:

Remember that the mediastinum is composed mainly of vascular structures. When a mediastinal abnormality is present, always rule out a vascular origin (arterial or venous).

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

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.

Dr. Pepe’s Diploma Casebook 153 – All you need to know to interpret a chest radiograph – Seventh Session

Dear Friends,

Today I am presenting the leading images of the seventh webinar. They belong to a 66-year-old man with vague chest complaints. Chest was read as normal, but there is a visible abnormality, difficult to see.
Can you see it?

Remember, you can see the previous sessions of the webinar in our youtube channel. We will published the answer to this question (and the webinar) on Friday.

Click here to see the answer

Findings: PA radiograph (A) is unremarkable. In the lateral view there is a nodule projected over the mid-thoracic spine (B, arrow). The nodule was overlooked, and the examination was read as normal.

One year later the nodule has increased in size (C, arrow) and has become visible behind the heart in the PA view (D, arrow). It was diagnosed as adenocarcinoma and liver metastases were found.

Two years later, CT and PET-CT show marked progression of the liver metastases.

Final diagnosis: lung adenocarcinoma missed in the first chest radiographs, with widespread metastases two years later
Congratulations to Spat, who discovered the initial nodule.
Teaching point: remember to look at the dorsal spine in the lateral view. By doing so, you may discover early disease, with great benefit for the patient.

Dr. Pepe’s Diploma Casebook 152 – All you need to know to interpret a chest radiograph – Sixth Session – SOLVED

Dear Friends,

Welcome to the new year and a new webinar. The leading images of the webinar six belong to a 73-year-old woman with dyspnea and chest pain. What do you see?


1. Intrathoracic goiter
2. Dilated esophagus
3. Aortic aneurysm
4. Any of the above

If you would like to see the previous webinars, check it here!

Click here to see the answer

You can see the webinar here.

Findings: PA radiograph shows widening of the right superior mediastinum (A, arrow), which in the lateral view is located behind the trachea (B, arrows). The initial impression is of an upper middle mediastinal mass. The first diagnosis that come to mind is a goiter.

However, looking downward in the PA view, bulging of the azygo-esophageal line is evident (A, red arrow). In the lateral view there is opacification of the retrocardiac space (B, red arrow). Therefore, we are dealing with a lesion that extends along the middle mediastinum from top to bottom. The findings point to a dilated esophagus.

Esophagogram was unremarkable. Coronal and sagittal CT shows a cystic tubular mass extending along the posterior wall of the esophagus (C-D, arrows).

Final diagnosis: cystic lymphangioma of mediastinum
This is a difficult case and I didn’t expect you to make the diagnosis. But I believe that you should have noticed the bulging of the azygo-esophageal line in the PA view and the occupation of the retrocardiac space in the lateral view, suggesting a dilated esophagus as the most likely diagnosis.
Congratulations to MG who was the first to see the findings.
Teaching point: Remember that an opacity that goes from top to bottom in the middle mediastinum should suggest a dilated esophagus or an esophagus-related process

Dr. Pepe’s Diploma Casebook 151 – All you need to know to interpret a chest radiograph – Fifth Session – SOLVED!

Dear Friends,

Showing today the leading case of the next webinar. PA radiograph belongs to an 86-year-old woman with chest pain.
What do you see?

More images will be shown on Wednesday. You can refresh your memory viewing the older webinars on our youtube channel.

Dear Friends, showing today a lateral film of the case. Hope it helps.

Click here to see the lateral film

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the left mid-lung field (A, arrow), better seen in the cone down view (B, arrow). The opacity is ill-defined, and my first impression would be an intrapulmonary lesion.

The lateral view shows that the opacity is located in the posterior chest wall. It has a typical pregnancy sign (C, arrow), indicating an extrapulmonary origin.
Enhanced axial CT confirms a low-density chest wall mass (D, arrow). Note the anterior displacement of the intercostal vessel (D, red arrow).

Final diagnosis: lymphoma of chest wall
Congratulations to all of you who diagnosed a chest wall lesion. Special mention to MK, who was the first to give the answer.
Teaching point: This case documents the importance of the lateral chest to clarify indeterminate findings in the PA radiograph.

Check the full webinar here

Dr. Pepe’s Diploma Casebook 150 – All you need to know to interpret a chest radiograph – Fourth Session

Dear Friends,

Presenting today the leading case of the next webinar. PA radiograph of a 58-year-old woman with cough and fever.

What do you see?

The answer will be published on Friday. While you wait, you can check the first three webinars, check the EBR youtube channel!

Click here to see the image

Click here to see the answer

Findings: PA chest radiograph shows an ill-defined opacity behind the right hemidiaphragm (A, red arrows), better seen in the cone-down view (B, red arrows). The fact that the opacity is visible indicates that it is surrounded by air, placing it in the right lower lobe.

A lateral view confirms air-space disease in the RLL (C, circle), blurring the posterior aspect of the right hemidiaphragm.

Final diagnosis: RLL pneumonia
Congratulations to archanareddyt who was the first to see the opacity and to MK who saw it and suggested the right diagnosis.
Teaching point: Remember that in the PA view the lower lobes go deep behind the diaphragm. Pulmonary disease of any kind can be seen in the upper quadrants of the abdomen, as demonstrated by the present case.

Remember to check the webinar published on the EBR youtube channel!

Dr. Pepe’s Diploma Casebook 149 – All you need to know to interpret a chest radiograph – Third Session – SOLVED

Dear Friends,

I am showing today the leading image of the third webinar. If you haven’t seen them, you can see the first one here and the second one here:

Chest radiograph belongs to a 24-year-old man with occasional episodes of fainting, currently asymptomatic.

What do you see?

Come back on Friday and enjoy the recording of the third webinar with the answer to this case and more information!

Click here to see the answer

Findings: PA chest radiograph shows convexity of the right outline of the middle mediastinum (A, arrow), suggesting dilatation of the ascending aorta. Some of you have mentioned aortic coarctation, which is not a good option because rib notching is not visible, and the aortic knob is unremarkable.
Given the patient´s age, a good possibility is congenital aortic stenosis.

Enhanced sagittal CT reconstruction shows dilatation of the ascending aorta (B, asterisk) and heavy calcification of the aortic valve (B, arrow). Axial CT demonstrated a malformed and calcified aortic valve (C, circle).

Final diagnosis: congenital aortic valve stenosis with post-stenotic dilatation

Congratulations to Renga, who was the first to mention the ascending aorta dilatation.
Teaching point: the middle third of the mediastinum is occupied by the aorta and pulmonary artery. Any mediastinal abnormality in this area should be suspected to have a vascular origin.

You can see on our youtube channel the webinar Prof. Cáceres has prepared discussing this case and others.

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

Dear Friends,

Today I am presenting the leading case of the second webinar. The PA radiograph belongs to a 62-year-old man with hemoptysis.

Is the radiograph abnormal?
If so, what do you see?

Starting this week, I have decided to stop giving live webinars. They will be recorded and published at the end of the week, together with the answer to the case. You can see the first session here

Click here to see the answer

Findings: PA chest radiograph shows convexity of the aorto-pulmonary window (A, arrow) and an opacity in the upper left hilum (A, red arrow). The findings were not present in a film taken three years earlier (B, circle) and suggest a pulmonary process with mediastinal adenopathy.

Findings were overlooked and the chest was read as normal. Six months later the patient returned with acute right chest pain. PA chest shows two triangular pleural-based opacities (C, arrows) suggestive of Hampton’s humps. The convexity at the APW is larger (C, green arrow) and the hilar opacity has increased in size (C, red arrow).

Coronal CT shows the typical appearance of pulmonary infarcts at the right lung base (D, arrows). There is large adenopathy at the APW (D, green arrow) accompanied by a lung mass (D, red arrow).

Final diagnosis: carcinoma of the lung with mediastinal metastases and associated pulmonary infarcts.
Congratulations to S, who made a brilliant diagnosis.
Teaching point: Remember the importance of checklists. If a checklist had been used in the initial radiography, a CT would had been taken and the tumor would had been discovered earlier

If you would like to learn more about this subject, check the webinar Prof. Cáceres recorded explaining this cases and others! You can also check the first webinar here.