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.

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.

Dr. Pepe’s Diploma Casebook – All you need to know to interpret a chest radiograph – First Session – CASE 147 – SOLVED

There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are the simplest things; and, because it takes a man’s life to know them, the little new that each man gets from life is very costly and the only heritage he has to leave

Dear friends, this quote from Ernest Hemingway serves as introduction to the next series of webinars. From October to March I intend to give a webinar every two weeks describing my basic approach to interpreting the chest radiograph. The subject is ample, and will continue with a second series in 2021.

To start, I am showing a preoperative PA chest radiograph for varices in a 60-year-old woman. The chest was read as normal, but there is an abnormality, difficult to detect.
Do you see it?

The answer was given during a webinar. You can watch the webinar here

Click here to see the answer

Findings: PA radiograph shows a small nodule overlapping the left cardiac border (A-B, arrows). The nodule was overlooked, and the chest was read as normal.

A chest radiograph taken four years later shows a marked increase in size of the nodule (C, arrow). Enhanced axial CT shows a non-enhancing low-density nodule (-30 H.U.)
(D, arrow). Needle biopsy confirmed the diagnosis of hamartoma.

Final diagnosis: Pulmonary hamartoma, overlooked in the initial film
 
Congratulations to Uve, who discovered the nodule with a little help.
 
Teaching point: Remember that overlooking visible findings accounts for 50% of our errors. Using checklists is an excellent way to change an error into a discovery.

Dr. Pepe’s Diploma Casebook – The art of interpretation – CASE 146 – SOLVED

Dear Friends,

Today I am presenting another “Art of interpretation case”, from last August.
Radiographs belong to a 22-year-old Spanish national with fever and dry cough for the last seven days. He had visited South Korea during the month of July. Chest radiographs read as normal by the Emergency Room physician.
What do you see?

More images will be shown on Wednesday.

Click here to see the images shown on Monday


Dear Friends,
showing several images of the enhanced CT.

What do you see?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows convexity of the aortopulmonary window (A, white arrow) and increased opacity of the left hilum (A, red arrow). The lateral view shows a faint opacity projected over the middle third of the thoracic spine (B, circle) that was overlooked in the initial reading.
The convexity of the APW suggested mediastinal lymphadenopathy, and CT was performed.

Coronal enhanced CT shows an enlarged lymph node in the APW (A, arrow). Axial CT depicts enlarged lymph nodes in the left hilum (B, circle). Lung window demonstrates air-space disease in the apical segment of the LLL (C, arrow), which explains the posterior faint opacity in the lateral view.

Summary of CT findings:

– Unilateral enlarged hilar lymph nodes
– Lymph node in APW
– Air-space disease in the apical segment of LLL

The most significant finding is the presence of unilateral hilar lymph nodes which have a limited differential diagnosis: in the great majority of patients they are due either to lung carcinoma or active tuberculosis. As this particular patient is 27 y.o., carcinoma is unlikely. Therefore, our tentative diagnosis should be active TB, which is also supported by disease in the apical segment of the LLL, a common location for TB.

The patient was placed in isolation, bronchoscopy was performed, and Mycobacterium tuberculosis was found in the aspirate.

Final diagnosis: active tuberculosis

YOUNG PERSON + UNILATERAL ENLARGED HILAR LYMPH NODES + PULMONARY INFILTRATE IN APICAL SEGMENT OF LLL = ACTIVE TUBERCULOSIS

Active pulmonary tuberculosis is not uncommon, and the chest radiograph plays an important role in its detection. Findings that help to suspect TB in the plain film are:

Location of the parenchymal disease. Involvement of the apices or the apical segment of either lower lobe should raise the possibility of a tuberculous infiltrate, although TB can affect any area of the lung.

Cavitation. The presence of cavities within a pulmonary infiltrate suggest tuberculosis or necrotic pneumonia.

Visible lymphadenopathies. Tuberculous lymph nodes are usually unilateral and located in the hilum and homolateral mediastinum. In about one third of patients they are bilateral. In such cases, lymphoma and sarcoidosis, among others, should also be considered.

CT refines these parameters by discovering cavitation or lymphadenopathy that is not evident in the plain film. The presence of low-attenuation lymph nodes due to caseous necrosis is highly suggestive of TB, although it is not pathognomonic. Other conditions can also show these features. However, normal-density lymph nodes do not exclude TB, as was seen in the present case.

Below, I show a few nice images of active TB in which low-attenuation lymph nodes
suggested the correct diagnosis.

CASE 1

23-year-old woman with cough and low-grade fever. Chest radiographs shows air-space disease in the RLL (A and B, white arrows). There is obvious widening of the right paratracheal line (A, red arrow), indicating mediastinal lymphadenopathy.

Enhanced axial CT confirms the RLL disease which is non-specific (C, arrow). No cavitations are visible. The mediastinal window shows numerous enlarged lymph nodes, some with a hypodense center (D and E, arrows) and others with peripheral enhancement (ring sign) (F, arrows).

Abdominal CT also shows enlarged mesenteric lymph nodes with the ring sign (G and H, circles).

It is interesting to note that lower lobe TB occurs in only 5% of patients. In this particular case the diagnosis of TB was suggested by the CT appearance of the affected lymph nodes. Mycobacterium tuberculosis was recovered from sputum.

Final diagnosis: active TB


Dr. Pepe’s teaching points:

1. Think of TB in unilateral hilar adenopathy in a young person.

2. Low-density lymph nodes on CT are highly suggestive of active TB, although normal-density nodes do not exclude it.