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?

1.Yes
2.No
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?

Diagnosis:

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.