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.

Cáceres’ Corner Case 214 – SOLVED

Dear Friends,

Presenting today radiographs of an 89-year-old woman with dyspnea and moderate fever.

Diagnosis:

1. Empyema
2. Mediastinal tumor
3. Pneumonia
4. None of the above

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

Click here to see the answer

Findings: PA chest radiograph shows an opacity occupying the middle and lower right lung It is located anteriorly in the lateral view and has a well-defined posterior border.
The clue to the diagnosis lies with the bubbles of air within the opacity (A, red arrows) which resemble bowel loops in the lateral view (B, circle). The heart is displaced towards the left, but this finding cannot be evaluated because of the moderate scoliosis. In addition, a hiatus hernia is present (A-B, arrows).

Enhanced axial CT (C-D) demonstrates that the opacity consists mainly of fat containing some bowel loops.

Coronal and sagittal reconstructions show a large gap in the anterior right hemidiaphragm (E-F, circles), with herniation of bowel and abdominal fat into the hemithorax.

Final diagnosis: large Morgagni´s hernia simulating pulmonary disease.
 
Congratulations to xristoby, who was the only one who mentioned anterior diaphragmatic hernia.
 
Teaching point: Remember that any lower lung lesion adjacent to the diaphragm may arise from the abdomen, as demonstrated with the present case.

Abdominal #5 – Long case

88-years-old female:
* Presents with acute abdominal pain and pain the right groin
* On clinical examination mass in the right groin
* Slightly elevated inflammatory parameters. Continue on next slide for coronal views.

What do you see?

Right-sided obstructed inguinal herniation with small bowel trapped. Mechanic small bowel ileus. As a coincidence Meckel’s diverticulum (not herniated). Engorgement mesentery but still normal enhancing bowel walls, no direct signs of bowel ischemia yet.


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.

Cáceres’ Corner Case 213 – SOLVED

Dear Friends,

Today’s radiographs belong to a 46-year-old man.
Preoperative for knee surgery.

What do you see?

Leave your thoughts on the comments and come back on Friday to see the answer!

Click here to see the answer!

Findings: PA chest radiograph show increased size of both hila (A, arrows), more evident in the right side. There is also convexity of the aorto-pulmonary window (A, red arrow). The findings are highly suspicious of widespread lymphadenopathy, confirmed in the lateral view (B, arrow). There is also anterior bowing of the posterior tracheal wall by a rounded opacity in Raider´s triangle (B, red arrows).

Enhanced axial CT confirms enlarged hilar lymph nodes (C, arrows) as well as an adenopathy in the A-P window (D-E, red arrows).

The retrotracheal opacity was due to an aberrant subclavian artery arising from a Kommerel diverticulum (F-H, red arrows).

The patient had been diagnosed of sarcoidosis in 2015. Follow-up CTs in 2017 and 2019 did not show any change.
 
Final diagnosis: Sarcoidosis with an incidental aberrant right subclavian artery.
 
Congratulations to Manal Gebril, who was the first to make the diagnosis and to Gaborini, who described the aberrant right subclavian artery.
 
Teaching point: remember satisfaction of search. Some of you missed the occupation of Raider´s triangle and nobody mentioned the convex A-P window.