Emergency #12 – Flashcard

31-year-old male:
* With flank pain
* Increased inflammatory parameters
* Decreased kidney function

Why is the right kidney less dense than the left?

Click here to see the answer

Obstructive kidney stone in the right proximal ureter (arrow) with secondary hydronephrosis

The increased pressure in the collecting system slows the ultrafiltration of urine and causes a slower enhancement of the right kidney in comparison with the left kidney, reflecting the impaired kidney function

Cáceres’ Corner Case 206

Dear Friends,

Now that Game of Thrones is ending, a new series is planned: Game of Thorax, in which either you diagnose or you die.

As you can see in today’s radiograph, the Iron Throne has been replaced by the Chest Throne.

What would your diagnosis be?

Come back on Friday to see the answer.

Dr. Pepe’s Diploma Casebook: CASE 142 – Art of interpretation – SOLVED

Dear Friends,

today I am presenting another “Art of interpretation” case. I like them and think they have good teaching value.
Radiographs were taken for preoperative knee surgery in a 21-year-old man.

What is the most likely diagnosis?

Diagnosis:
1. Swyer-James-McLeod syndrome
2. Congenital hypoplasia of left lung
3. LUL collapse
4. None of the above

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a hyperlucent left lung with a small elevated hilum (A, white arrow). The trachea is deviated towards the left and the left main bronchus is curved upward (A, blue arrow). There is a small peak in the left hemidiaphragm (A, red arrow). And there is a triangular-shaped paraspinal opacity (A, circle), better seen in the cone down view (B, white arrow), with two linear metallic opacities inside (B, red arrows).

The lateral view (C) is unremarkable. Although the PA findings suggest loss of volume of the LUL, there are some negative findings: no anterior displacement of the left major fissure and no opacity indicative of LUL collapse.

Analysis of the findings

There are four obvious findings:

1. Hyperlucent left lung with small left hilum
2. Tracheal deviation to the left
3. Upward curving of left main bronchus
4. Juxtaphrenic peak (*)

All these findings are indicative of LUL volume loss with compensatory overinflation of the LLL.

There are two less obvious findings, which are diagnostic:

Paramediastinal opacity with surgical staples
No signs of LUL collapse in the lateral view

The first indicates previous surgery and the second excludes LUL collapse. Taken together, these findings lead to the obvious conclusion that the patient had undergone a previous lobectomy.

(*) The juxtaphrenic peak sign was described by my late friend Kenneth Kattan as an indirect sign of LUL collapse. Semin Roentgenol 1980; 15:187-193

LOSS OF VOLUME OF LUL + SURGICAL STAPLES = LUL LOBECTOMY

In the past, the patient had embryonal carcinoma of the testicle with a metastatic nodule in the LUL (A and B, arrows). He had undergone LUL lobectomy by video-assisted thoracic surgery one year before.

Final diagnosis: LUL lobectomy for metastasis of embryonal testicular carcinoma

I’m showing this case to emphasize the importance of identifying metal sutures in the chest radiograph. Nowadays, most surgical procedures are done by video thoracoscopy which doesn’t leave any telltale signs other than surgical staples. These are difficult to see because of their small size and because high kV “burns” metal density.

Staples are visible as a faint longitudinal ring chain somewhat denser than the surrounding tissues. It’s very important to be familiar with their radiographic appearance because they offer valuable information about previous surgery.
When staples are detected, our interpretation of associated findings may change, as occurred with the case presented.

To familiarize you with the radiological appearance of surgical staples, I’m showing three more cases.

CASE 1:

88-year-o.ld man with dementia and moderate dyspnea. Chest radiographs show a nodule in the RUL (A and B, arrows). PA view shows post-surgical changes at the left 6th and 7th ribs and a hyperlucent left lung with a small hilum. There are surgical clips in the mediastinum (A and B, red circles). These findings suggest a previous LUL lobectomy and a second primary tumor. The patient’s records disclosed a LUL lobectomy for carcinoma twenty years earlier. The second primary tumor was confirmed by needle biopsy.
The radiographic findings are typical of “old” chest surgery.

CASE 2:

PA radiograph of a 23-year-old woman with a nondescript LUL infiltrate (A, arrow). Close-up view reveals a longitudinal ring chain of staples within the infiltrate (B, arrows), pointing to a man-made opacity secondary to video thoracic surgery.

Diagnosis: changes after endoscopic LUL bullectomy for recurrent pneumothorax.

CASE 3:
I saw this case three weeks ago and it is still unproven. A 44-year-old woman from another country came for a routine cardiac checkup. The PA chest radiograph shows a serpiginous opacity in the LLL (A, arrow) with a ring chain of staples in the periphery, better seen in the cone down view (B, arrows). On questioning, the patient mentioned previous endoscopic surgery for a nodule in the left lung two years ago. Enhanced CT shows a solid lesion with staples in the periphery (C, arrow).

As the patient could not provide previous medical records, we were unable to ensure that the changes were attributable to scar tissue. A follow-up CT has been scheduled.

Final words: Staples are difficult to reproduce on the computer screen, and I have done my best. I assure you that they are easily visible on a 14 by 17 reading console, provided that you see and recognize them 🙂


Follow Dr. Pepe’s teaching points:

1. Surgical staples are visible as a faint longitudinal ring chain.

2. They indicate previous surgery and help to interpret the chest findings under a new light.

Emergency #11 – Long case

23-year-old male:
* HET
* 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.