Dr. Pepe’s Diploma Casebook: The wisdom of Dr. Pepe: CASE 132 – SOLVED

Dear Friends,

I would like to start a new section entitled “The wisdom of Dr. Pepe”. I like aphorisms and in this section I would present an aphorism that will summarise the teaching point of the cases presented.

Today I want to show two different cases. Radiographs of Case 1 belong to 86-year-old woman with chest pain. Pulmonary abnormalities are unchanged in comparison with a  radiograph taken one year earlier.

Check the images below, leave your thoughts in the comments section. We will publish new images on Wednesday and the answer on Friday!

Click here for the see the images for CASE 1

1. TB granulomas
2. Bronchioalveolar carcinoma
3. Amyloid nodules
4. None of the above

Click here for the answer for CASE 1


PA radiograph show widening of the left mediastinum caused by an elongated aorta (A, arrow). The right mediastinum is also widened, going all the way up to the neck (A, red arrows) with a visible air-fluid level at the top (A, yellow arrow). The appearance is typical of a dilated esophagus. The lateral view shows similar findings, with the trachea pushed forward by the dilated esophagus (B, red arrows) and a posterior double contour which represents the descending aorta (B, arrow).
Small pulmonary nodules are visible in both lungs.

Axial CT confirms the marked dilatation of esophagus (C, arrow) and the pulmonary nodules. There are also enlarged lymph nodes in the mediastinum (D, arrows).
The combination of dilated esophagus and pulmonary nodules suggests two possible etiologies: carcinoma of distal esophagus with metastases or achalasia with aspiration. In this particular case, the pulmonary lesions did not change for two years, which exclude metastases and points to post-aspiration granulomas. It is well known the relationship of achalasia with pulmonary infection by atypical Mycobacteria.

Final diagnosis: achalasia (surgically proved) with pulmonary aspiration, possibly atypical TB granulomas (unproven).

Radiographs of Case 2 belong to a 23-year-old woman with cough and low-grade fever.

Click here for the see the images for CASE 2

Dear friends,

Showing CT images of the chest. Do they help you?

Click here for the see the more images for CASE2

1. Tuberculosis
2. Chronic aspiration
3. Lymphoma
4. None of the above

Click here for the answer for CASE 2


PA and lateral chest show non-specific air-space disease in the right lower lobe (A-B, arrows). In addition, there is marked widening of the right paratracheal line (A, red arrow) suggestive of mediastinal lymphadenopathy.

Axial CT with lung window shows air-space disease in the RLL. The appearance is non-specific and there is no stretching of the bronchi (leafless tree) which, when seen, is typical of lymphoma.
Enhanced axial CT confirms enlarged lymph nodes in several locations. All of them have hypodense centers (D-F, arrows). Lymph nodes with hypodense center may occur in several processes (treated tumors, Whipple’s, etc.), but in the appropriate clinical situation, the first diagnostic consideration should always be tuberculosis. Although TB usually affects upper lobes, involvement of lower lobes can occur.

Final diagnosis: tuberculosis of RLL with widespread mediastinal adenopathy.

Congratulations to Olena and MK for their participation and correct diagnosis.

I am showing these cases to emphasize the importance of examining carefully the radiographic images. Aside from having the same etiology (TB), both cases have multiple findings and the sum of all of them are the clue to the right diagnosis.
In satisfaction of search, findings are missed because we don’t search for additional abnormalities after the first one is found. When there are multiple findings, additional ones are discovered less than 50% of the time.
So, once again, try to avoid satisfaction of search. Remember that it accounts for approximately 22% of our errors.

Follow Dr. Pepe’s advice:

Don’t let one abnormal finding keep you from looking for another.