31-year-old male with:
* Right upper quadrant & epigastric pain
* History of gastric bypass surgery
Whirlpool sign
The transition point from dilated small bowel (with the “small bowel feces sign”) to non-dilated small bowel at the site of internal herniation through a mesenteric defect.
Hello friends,
After three weeks of confinement I believe I have seen all TV series available. If you like Sci-Fi I recommend The Expanse (Amazon Video) and for older citizens The Kominsky method(Netflix).
Today’s case was sent to me from my hospital in the early days of lockdown. The scout film belongs to a 78-year-old man with doubtful COVID-19 infection.
Do you see any abnormality?
If so, where is it?
1. Chest
2. Abdomen
3. Chest and abdomen
4. Don’t see it
Findings: There is a rounded right mediastinal opacity at the junction of the trachea and right main bronchus (A, arrow). There is an apparent abdominal RUQ mass (A, red arrows) with an area of lesser opacity in the center (A, yellow arrow).
The correct answer would be number 3. Visible abnormalities in chest and abdomen
With these findings what would be your diagnosis?
1. Enlarged azygos arch
2. Azygos continuation of IVC
3. Right-sided stomach
4. All of the above
The clue to the diagnosis resides in the apparent RUQ abdominal mass. The shape suggests a right-side stomach, with air in the antrum and duodenal bulb and lesser amount of air in the fornix (Fig A). Findings are better seen in the drawing (B).
A right-sided stomach with a normal-positioned heart is highly suggestive of a congenital abnormality, levocardia with abdominal situs inversus. In this malformation the chest structures are in their normal location, whereas the abdominal viscera are rotated 180 degrees.
This malformation is accompanied by partial interruption of the IVC and azygos continuation, which results in an enlarged azygos arch.
Therefore the correct answer is 4. All of the above
Enhanced axial CT confirms the enlarged azygos arch (A, arrow). Coronal reconstruction demonstrates the dilated ascending azygos vein (B, arrows)
Axial images of the upper abdomen show the gastric fornix in the RUQ (C-D, arrows) as well as a normal left-sided heart (C) and a mid-line liver (D). There is a small splenic remnant in the RUQ (D, red arrow).
Final diagnosis: Levocardia with abdominal situs inversus
I am showing this case because this is our fourth patient with levocardia and abdominal situs inversus seen in the last four years (see Caceres´ corner cases 178 & 194 and Dr. Pepe´s Summer case 1). It may not be as rare as the textbooks state. In addition, the diagnosis can be suggested in the plain film if we discover the right-sided stomach.
Dear Friends,
Today I am showing a preoperative chest radiograph for varices of a 60-year-old woman.
Do you see any abnormality?
If so, where is it?
1. Lung
2. Mediastinum
3. Pleura/chest wall
4. Don’t see it
Findings: There are bilateral convex opacities in the lower mediastinum (A, arrows), better seen in the cone down view (B, arrows). The appearance suggests a lower central mediastinal mass and the most likely diagnosis should be hiatus hernia. A fact against this diagnosis is the gastric fornix in its normal location (A, red arrow).
What would you recommend:
1. Lateral view of the chest
2. Esophagogram
3. Chest CT
4. None of the above
In my opinion, the best choice is a lateral view, which shows poor definition of the body of the eleventh dorsal vertebra with a sharp angulation of the spine (C, circle). There is no evidence of hiatus hernia.
AP cone down view of the lower thoracic spine shows a butterfly deformity of D11 (D, circle) with the outer borders accounting for the convexities visible in the chest radiograph. Lateral cone down view confirms marked flattening and collapse of the vertebral body (E, circle)
The patient had been involved in a car accident five years ago resulting in a burst compression fracture of D11. Comparison with previous radiographs did nor show any change.
Final diagnosis: Traumatic compression fracture of D11, stable
Teaching point: Remember that not all opacities in the lower mediastinum in the PA view are hiatus hernias. A lateral view places them in the correct compartment and helps to clarify the etiology.
Dear friends, starting today I plan to show simple teaching cases (vignettes) hoping to ease the boredom of the confinement.
I will show two cases every week (Monday and Thursday). To make the presentation more agile the diagnosis will be included. If you get impatient all you have to do is press the answer button.
The first case is a routine control PA radiograph in a 67-year-old woman operated on for breast carcinoma three years ago.
Question: Do you suspect any bone metastasis?
Findings: There is an apparent lytic lesion in the distal end of the right clavicle (A, arrow), better seen in the cone down view (B, arrow).
When I saw this case two months ago, I could not determine whether the lesion was real or not. What would you do?
1. Compare with previous films
2. Call the oncologist
3. PET-CT
4. Bone scintigraphy
In my opinion, the first thing to do was comparing with previous films although
this brilliant idea was hampered by the technician placing the marker in top of the distal clavicle in two earlier radiographs (C-D).
What would you do now?
1. Bone scintigraphy
2. Call the oncologist
3. PET-CT
4. CT
Since I was not sure about the lesion, I decided to call the oncologist to find out if she suspected any metastasis and if the patient had any pain in the right acromioclavicular area. The answer was negative. What would you recommend?
1. Bone scintigraphy
2. CT
3. PET-CT
4. Radiograph of the right clavicle
In my opinion the fastest way to clarify the diagnosis was to take a radiograph of both clavicles (with the left for comparison). The distal end of the right clavicle has a normal appearance and , since the patient had no local symptoms, no further studies were needed.
Final diagnosis: normal variant simulating pathology in an oncologic patient
I have seen several chest radiographs with apparent lytic lesion of the distal clavicle that turned out to be normal. It is described in the Atlas of normal variants by Keats. In this case I was doubtful because the patient had a carcinoma and the appearance of the lesion was ominous.
There are two teaching points in this case:
1. Talking to the referring physician is important to determine the management of findings.
2. A simple and inexpensive procedure clarified the diagnosis and avoided unnecessary additional studies.
14-year-old boy:
– Actue pain left hemiscrotum
What is the most likely diagnosis?
Acute torsion testis
– Less/no vascularisation – flow with color Doppler-affected testicle
– Lower echogenicity or heterogeneous aspect testicle, if too late already hypoechoic infarcts
– Testicle displaced cranially in the scrotum
– Twisted spermatic cord “like a knot”
– Reactive hydrocele
Below you can see images from a companion case:
Dear Friends,
Today’s radiographs belong to a 27-year-old woman who came for a routine check-up.
Most likely diagnosis:
1. Thymic tumor
2. Enlarged lymph nodes
3. Aortic arch malformation
4. None of the above
CT images will be shown next Wednesday.
Dear Friends,
Today I am showing enhanced CT images of the mediastinum in the early (A-B) and late phases (C-E).
What do you think?
Findings: PA chest radiograph shows a right upper mediastinal mass with undulated border (A, arrow). There is increased opacity of the anterior clear space in the lateral view (B, circle). In my opinion, the most likely diagnosis would be thymic tumor, although the undulated border favors enlarged lymph nodes.
Enhanced axial CTs in the arterial phase show an anterior mediastinal mass with minimal enhancement (C-D, arrows) and a vascular space in the center (C, yellow arrow).
Coronal and axial CTs in the late phase show partial washout of the vascular space (E, yellow arrow). The clue to the diagnosis lies in the presence of several punctate calcifications within the mass (F-G, red arrows) consistent with phleboliths, which are practically diagnostic of hemangioma. The central vascular space also supports the diagnosis.
The patient had been diagnosed of mediastinal hemangioma two years earlier and comparison with previous chest films and CTs did not show any change.
Final diagnosis: Mediastinal hemangioma
Congratulations to Naegleria and MK who gave similar diagnosis both at exactly 12:55 P.M.
Teaching point: This case is unusual (I have seen only two of them in the mediastinum) but can be easily diagnosed if phleboliths are present (and recognized). Early in my residency I learned that, when finding phleboliths within a mass, the diagnosis should be hemangioma until proven otherwise.
Ref. HP McAdams, ML Rosado de Christenson, CA Moran. Mediastinal hemangioma: radiographic and CT features in 14 patients. Radiology 1994; 193:399-402
45-year-old male:
– Presenting with mixed hearing loss.
What do you see on the image? What is the most likely diagnosis?
Diffuse fenestral and retrofenestral otosclerosis
Dear Friends,
Today’s radiographs belong to a 37-year-old man with moderate fever.
What do you think?
Come back on Friday to see the answer!
Findings: Chest radiographs show an intrapulmonary rounded opacity with ill-defined borders in the left lung (A-B, arrows). In a patient with fever and no other significant symptoms, the most likely diagnosis should be rounded pneumonia, although I was somewhat concerned about the good definition of the lower contour in the lateral view (B, red arrows), which is unusual in pneumonia.
The patient improved with treatment and follow-up radiographs four weeks later show only minimal residual findings in the PA view (C, arrow).
Final diagnosis: rounded pneumonia simulating a pulmonary mass.
Congratulations to Ahmad, who was the first to give the correct diagnosis. Silver medal to Sara Mercado/span>, who arrived second three hours later.
Teaching point: remember that not all pulmonary nodules/masses are malignant. If you want to know more about them, look up Diploma #51 “Innocuous pulmonary nodules”
12-year-old boy, asymptomatic:
Lytic lesion on distal fibular metaphysis with well-defined sclerotic borders is seen on both anteroposterior (a) and oblique (b) radiographs
– Most common fibrous bone lesion
– Same as fibrous cortical defect but larger version
– If large enough, may cause pathological fractures
– One of DON’T TOUCH lesions
Today’s radiographs belong to a 77-year-old man with dyspnea.
Diagnosis:
1. Allergic aspergillosis
2. A-V malformations
3. Chronic changes post-TB
4. None of the above
What do you see? Come back on Friday to see the answer 🙂
Findings: PA chest radiographs shows elongated opacities apparently arising from the hila (A, arrows). The lack of branching goes against mucous impactions. The clue to the diagnosis lies in the calcified pleural plaque in the right hemidiaphragm (A, red arrow), which is a sign that strongly suggests asbestos exposure.
This diagnosis is corroborated by the lateral view, which shows calcified pleural plaques in the anterior clear space (B, red arrow).
Previous AP and oblique rib radiographs after chest trauma show the undulated calcified plaque in the right hemithorax (C-D, arrows).
Unenhanced coronal CT confirms the plaque in the right hemidiaphragm (E, arrow). Axial CTs demonstrate the anterior plaques (F-G, red arrows), as well as the unaffected lung (F).
Final diagnosis: calcified pleural plaques simulating pulmonary disease.
Congratulations to Phi Pham, who was the first to make the correct diagnosis.
Teaching point: Remember that superimposed opacities may simulate intrapulmonary pathology.
