Dr. Pepe’s Diploma Casebook: CASE 141 – SOLVED

Dear Friends,

Today I am showing radiographs of a 47-year-old woman with chronic cough.
What do you see?

Leave your comments here and come back on Friday to see the answer.

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Findings: PA radiograph shows marked downward displacement of the right hilum (A, white arrow) and verticalization of the intermediate bronchus (A, red arrow). These findings are indicative of marked volume loss of RLL. The lateral view (B) is unremarkable.

Enhanced coronal CT confirms the descended right hilum (C, white arrow), as well as the vertical intermediate bronchus (C, red arrow). A different slice shows a small calcified triangular shadow (D, arrow), which represents a markedly collapsed RLL.

Final diagnosis: severe RLL collapse due to previous TB

In the previous webinar (Diploma case 139), I described the common signs that suggest lobar collapse. In this presentation I want to review atypical forms of lobar collapse and how to recognize them.
The main signs of lobar collapse are volume loss and increased opacity of the lobe. Atypical presentations lack these traits, and the lobe appears to have an increased volume (drowned lobe) or to have collapsed without increased opacity (aerated collapse). A third variant would be a lobe that has lost most of its volume (extreme collapse) and therefore is difficult to identify as such, as occurred in the initial case.

In extreme collapse, the affected lobe is severely decreased in size and may be overlooked, or confused with a different process (Fig. 1). The diagnosis is suggested by secondary findings, such as hilar displacement and/or increased lucency of the unaffected lobe(s) (Figs. 2 and 3).

Fig. 1. 57-year-old man with carcinoma of the RUL bronchus causing severe RUL collapse. The medial displacement of the collapsed lobe simulates mediastinal widening (A, white arrow). The clue to the diagnosis is a small and slightly elevated right hilum (A, red arrow). The lateral view (B) is unremarkable.

Enhanced axial CT image depicts a horizontal sliver of tissue, corresponding to the markedly collapsed RUL, sharply outlined by the minor fissure (C and D, white arrows). Note the obstructed RUL bronchus (D, red arrow). Bronchogenic carcinoma.

Fig. 2. Pre-op film for cataracts in a 72-year-old man. PA chest film shows a lucent left lung. Severe LLL collapse is suspected because of the downward left hilar displacement (A, white arrow) and a triangular-shaped paramediastinal opacity (red arrow). The posterior left hemidiaphragm is blurred in the lateral view (B, arrow).

Enhanced axial CT shows the markedly collapsed lobe (C, arrow). Coronal CT depicts a mass obstructing the LLL bronchus (D, arrow). Final diagnosis: carcinoma.

Fig. 3. 67-year-old woman with extreme LUL collapse secondary to previous TB. The diagnosis is suspected because the collapsed lobe causes haziness of the left mediastinal border in the PA film (A, arrows). The expanded LLL causes increased lucency of the left hemithorax. Lateral view shows marked anterior displacement of the left major fissure (B, arrows).

Coronal and sagittal CT confirm the extreme LUL collapse with bronchiectasis. The major fissure is well depicted in the coronal and sagittal reconstructions (C and D, arrows).

The finding known as drowned lobe is a variant of lobar collapse in which the lobe does not decrease in size but instead, enlarges. It occurs when a slow-growing proximal tumor permits accumulation of distal secretions and infection, causing an increase in size of the lobe (Fig. 4). Bulky tumor masses may contribute to this enlargement (Fig. 5).

Fig. 4. 55-year-old woman with widespread lung disease and a large opacity occupying the upper two thirds of the right lung in the PA radiograph (A, white arrows). The right hilum (A, red arrow) is in a normal position. The lateral view shows that the opacity corresponds to an enlarged RUL (B, arrows).

Enhanced axial and coronal CT shows the enlarged RUL lobe (C and D, white arrows), secondary to central obstruction of the RUL bronchus (C and D, red arrows). Diagnosis: drowned RUL secondary to central carcinoma

Fig. 5. 47-year-old woman with drowned LLL, which appears in the PA radiograph as a uniform mass occupying the lower two thirds of the left lung (A, arrow), recognizable in the lateral view as a swollen LLL (B, arrows).

Enhanced axial CT confirms the swollen LLL (C, white arrow). PET-CT shows that part of the bulk is due to a large tumor mass (D, white arrow), invading the pulmonary veins and left atrium (C and D, red arrows).

In aerated collapse the lobe loses volume, but does not increase in opacity, making the collapse less obvious. This happens because increased opacity is not related with volume loss, but rather with the amount of secretions within the lobe. If the partially collapsed lobe contains air, the lobe will appear to have normal lucency.
In aerated collapse, the diagnosis is suspected by displacement of the hilum, the fissure, or both (Figs. 6-8).

Fig. 6. Aerated RLL collapse in carcinoma. PA chest film depicts a right hilar mass (A and B, red arrows), with a descended hilum. The lowered major fissure is barely visible (A, white arrow). In the lateral view, the collapsed lobe is seen as a faint opacity projected over the spine (B, white arrow). Bronchoscopy confirmed an endobronchial carcinoma.

Fig. 7. Aerated RLL collapse secondary to bronchiectasis. PA radiograph shows a markedly displaced major fissure simulating an inferior accessory fissure (A, white arrow). There is marked downward displacement of the right hilum (A, red arrow). Coronal CT confirms the findings (B, red and white arrow), with bronchiectasis and an open RLL bronchus

Fig. 8. 75-year-old man who had TB in his youth. Chest radiographs show aerated collapse of the LUL, demonstrated in the PA view by the small elevated left hilum (A, arrow) and by the anterior displacement of the major fissure in the lateral view (B, arrows). Note that the LUL is well aerated.

Follow Dr. Pepe’s advice:

1. Common manifestations of lobar collapse are loss of volume and increased opacity.

2. Uncommon manifestations of lobar collapse are extreme collapse, drowned lobe, and aerated collapse.

3. These uncommon manifestations are suspected based on secondary signs: hilar and/or fissure displacement and increased lucency of the unaffected lobe(s).

Emergency #11 – Long case

23-year-old male:
* Macroscopic hematuria and blood at urine meatus

What is the most likely diagnosis? What should we do next?

Click here to see the answer

 X-ray: Bilateral pelvis fractures discontinuity iliopectineal line most clearly left-sided

CT: Bilateral ramus superior/anterior iliac bone and ramus inferior pubic bone
Avulsion fracture symphysis pubis
Fracture sacrum on the right

Look also in soft-tissue setting!

Large hematoma posterior of symphysis pubis around urethra and perineum, lateral around the pelvic floor obturator internus muscles and cranially in the retroperitoneal Retzius space anterior of the bladder

Do a RUG: Retrograde Urethrogram. If intact, followed by CT Cystography

RUG shows contrast extravasation and complete rupture of anterior bulbous part of urethra, grade V isolated anterior injury. However, the rupture might be at the anatomic weak point, the bulbomembranous junction, meaning avulsion of the puboprostatic ligament and stretching of the membranous urethra. There is no contrast above the urogenital diaphragm (level of symphysis pubis). Contrast in the bladder is a residue from the IV contrast given for earlier total body CT.

Goldman classification urethral injury

Anterior urethra = Penile and bulbous part
Posterior urethra = Membranous and prostatic part

  • Type I: stretching the posterior urethra due to disruption of puboprostatic ligaments and hematoma, but urethra is intact
  • Type II: posterior urethral injury above urogenital diaphragm (between ischiopubic rami)
  • Type III: injury to membranous urethra, extending into the proximal bulbous urethra (i.e. with laceration of the urogenital diaphragm), thus contrast extravasation below diaphragm
  • Type IV: bladder base injury involving bladder neck and proximal urethrainternal sphincter is injured, hence the potential for incontinence
  • Type IVa: bladder base injury, not involving bladder neck (cannot be differentiated from type IV radiologically)
  • Type V: anterior urethral injury (isolated)

* In this case, no CT cystography was performed
* Patient was treated conservatively

Cáceres’ Corner Case 204 – SOLVED

Dear Friends,

Today’s radiographs belong to a 54-year-old man with chest pain.

More images will be shown on Wednesday.

What do you see?

Click here to see the images

Dear Friends,

Showing new images of the thoracic cage. 

What do you think?

Click here to see the new images

Click here to see the answer

Findings: PA radiograph shows an extrapulmonary lesion in the left hemithorax (A, arrow). The 3rd left rib is broadened (A, red arrows) and the distal segment is not visible.
There is a lineal infiltrate in the adjacent lung and at the left lung base. In addition, an expansive lytic lesion is visible in the anterior 7th right rib (A, yellow arrow).
The lateral view (B) does not show any significant findings.

AP and oblique views of the thoracic cage show an expansive lesion of the 3rd left rib (C-E, arrows) and confirm the expansive lytic lesion of the right 7th rib (C-E, red arrows). There is also a pure lytic lesion of the 8th left rib (C-E, red circle). There is minimal loss of height of D-11 (C and E, blue circle).

Discovering expanding lesion of the ribs should suggest either multiple myeloma or metastases (renal cell carcinoma, thyroid carcinoma). In this patient a multiple myeloma was found.
Final diagnosis: multiple myeloma, IgA type.
Congratulations to VL who found the bone lesions in the initial radiographs (many of you ignored satisfaction of search) and to archana reddy.t, who made the final diagnosis.
Teaching point: remember to look at the underlying rib in any extrapulmonary lesion. Discovering rib involvement focus your diagnostic approach and limits the differential diagnosis.

Neuroradiology #11 – Long case

47-year-old male:
* Presented with epistaxis

Axial & coronal CT+C

Where is the lesion?

The bulk of the tumour is within the ethmoid sinuses extending inferiorly into the nasal cavity and superiorly into the intracranial cavity through the cribriform plates

What is the lesion like?

Enhancing soft-tissue tumor expanding the ethmoid sinuses and nasal cavity

T2, T1 and T1+C

What are the MRI signal characteristics?

Mixed signal intensity on T2, low signal on T1, and intense enhancement on post-contrast images

What is the differential diagnosis of paranasal sinus tumour?

* Olfactory neuroblastoma:  involves the ethmoid sinuses  and extends through the cribriform plate into the anterior cranial fossa. Usually, shows intense enhancement and may show calcifications. They are slow growing with sinus expansion

* Juvenile angiofibroma: benign locally aggressive vascular  tumor that affects adolescents. It is usually lobulated and expands the sphenopalatine foramen. Intense enhancement on post-contrast images

* Sinonasal carcinoma: heterogeneously enhancing mass that erodes the bone and may extend into the orbits or intracranially

* Lymphoma: low T2 signal with intense contrast enhancement and usually expands the bone

Diagnosis:Olfactory neuroblastoma

Dr. Pepe Case 140 – Art of interpretation – SOLVED!

Dear Friends,

I am presenting today a new “Art of interpretation” case.
Radiographs belong to a 51-year-old with chest pain, dyspnea and D-dimer of 750.

1. Pulmonary infarct
2. Pneumonia
3. Chronic pulmonary changes
4. None of the above

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

Click here to see the images

Click here to see the answer

Findings: the PA radiograph shows an ill-defined opacity in the right mid-lung field (A, white arrows) which looks intrapulmonary. There is blunting of the right costophrenic angle, indicative of pleural disease (A, red arrow).

The main diagnostic findings are seen in the lateral view. There are oblique posterior pulmonary strands (“crow’s feet”) (B, white arrow) which lead our attention to a posterior vertical white line (B, red arrows), which represents calcified pleura.
A negative finding is the absence of pulmonary disease in the lateral view.

These findings are better seen in the cone down views (C and D, arrows) .

Analysis of findings:
1. Apparent pulmonary disease in the PA radiograph
2. No visible pulmonary disease in the lateral view
3. Blunting of costophrenic angle with calcified posterior pleura
4. Crow’s feet

Summing up the findings: The apparent pulmonary disease in the PA view, which was not seen in the lateral view, together with chronic pleural disease (evidenced by blunting of the costophrenic angle and calcified posterior pleura) are highly suggestive of pleural disease simulating a pulmonary infiltrate.


Enhanced axial CT confirms the posterior calcified pleura (A, arrow), the lack of pulmonary infiltrate, and the crow’s feet adjacent to the diseased pleura (B, red arrow).
Crow’s feet are better seen in the coronal and sagittal reconstructions (C and D, red arrows), especially the sagittal view, which is practically identical to the lateral chest radiograph.

Final diagnosis: Pleural calcification simulating pulmonary infiltrate

(My heartfelt thanks to Dr. Eva Castañer for providing the CT images)

Pleural calcifications are not uncommon. Bilateral calcifications are almost always related to asbestos exposure. Unilateral calcifications are usually due to a previous infection or hemorrhage. In any case, when located in the anterior or posterior chest wall they are seen en face in the PA radiograph and may be confused with pulmonary infiltrates, as in the present case. Seen in profile in the lateral view they appear as a calcified line, and the diagnosis is then evident.

Sometimes, the calcified pleura are overlooked. In this particular case we have a useful marker that points our attention to the diseased pleura: the radiologic sign known as crow’s feet which represents subsegmental areas of peripheral fibrosis/atelectasis fixed by the fibrotic pleura. They are likely an early stage of rounded atelectasis. (Personally, I prefer the alternative term sun rays rather than crow’s feet. As a frequent visitor to Minorca, I am more familiar with sun rays than with crows, let alone their feet).

To emphasize the deceitful appearance of pleural calcification, I am showing two more cases.


Radiographs belong to a 52-year-old asymptomatic woman. The PA radiograph shows what appears to be a poorly-defined pulmonary infiltrate in the left lung (A, arrow). The lateral view shows two calcified pleural plaques: the posterior one is depicted as a calcified line (B, white arrow), whereas the anterior one is more oblique and simulates a rounded opacity (B, red arrow).

Sagittal CT clearly shows the anterior (C, arrow) and posterior plaques (D, arrow). No pulmonary infiltrates were seen in the lung view (not shown).


Preoperative PA chest radiograph in a 57-year-old man. There are several opacities in the left hemithorax that may be pulmonary infiltrates (A, white arrows) accompanied by left diaphragmatic and pleural calcifications (A, red arrows).

In the coronal CT (B) there are no lung abnormalities. Enhanced axial and sagittal CTs depict extensive pleural calcification (C and D, arrows). The apparent pulmonary infiltrates were due to pleural calcifications depicted en face. The patient had a history of TB in his youth.

Dr. Pepe’s teaching points:

1. Pleural disease can simulate pulmonary infiltrates.

2. Crow’s feet can direct our attention to overlooked pleural disease

Emergency #10 – Long case

23-year-old male:
* Blunt force trauma of the abdomen
* Patient is hemodynamically stable

What do you see?

Arterial phase

Venous phase

Arterial phase

Venous phase

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* Linear zone of hypodensity through the pancreatic body on both phases
* Surrounding fluid with relatively high-density retroperitoneal AND intraperitoneal

Note that the pancreas may appear normal in 20%-40% of patients when CT is performed within 12 h after trauma
MRCP may be useful to evaluate the integrity of the pancreatic duct

Pancreatic fracture:

* Complete laceration of the pancreatic body: AAST Grade III
* Require surgery within 24h
* Possible complications: fistula, pseudocyst, pancreatitis, abscesses, hemorrhage, pseudo-aneurysm
* Usually, injuries of other organs as well

Treatment in this case: distal pancreatectomy and closing of main pancreatic duct transsection, discharge to hospital in home country after 2 weeks