Cáceres’ Corner Case 219 – SOLVED!

Dear Friends,
Today’s images belong to a 67-year-old woman with pain in the chest.
What do you see?

More images will be presented next Wednesday and the answer will be published on Friday, as usual.

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Dear Friends,

Showing additional axial CT images of the patient.
What do you see?

Click here for the solution

Findings: PA chest radiograph shows a lytic lesion of the 3rd right rib, accompanied by an extrapulmonary sign (A, circle). Lateral view (not shown) is unremarkable.

The lesion is more obvious in the cone-down view (B, circle), specially when compared to a previous study (C, circle).

Axial CT confirms a permeative lesion of the rib (D-E, arrows), as well as lytic lesion in the posterior elements of the 4th thoracic vertebra (E, red arrow). A serendipitous finding is a nodule in the medial quadrant of the left breast (F, arrow), demonstrated in a subsequent mammography (G, arrow) and confirmed to be a carcinoma.

Final diagnosis: carcinoma of the breast with osseous metastases
 
Congratulations to Diogo who saw and described the rib lesion in the plain film.
 
Teaching point:remember that our most common error is missing obvious lesions.
Checklists help to correct oversights. I believe the rib lesion could have been found if you had applied the checklist recommended in webinar one (H).

Cáceres’ Corner Case 215 – SOLVED

Dear Friends,

Today’s case has been provided by my good friend and former resident Victor Pineda. Radiographs belong to a 56-year-old man with cough and fever.
What do you see?

More images will be shown on Wednesday!

Click here to see the images shown on Monday

Dear friends hope these new images help you with the diagnosis.

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Click here to see the answer

Findings: PA chest radiograph shows a large paramediastinal lung opacity (A, arrow) that at first glance suggest malignancy. The clue to the diagnosis lies in identifying multiple bronchiectasis in the right and left central lung fields (A, circles).

The lateral view confirms the opacity in the posterior segment of the RUL (B, arrow) and bronchiectasis in the anterior clear space (B, circle).

Central bronchiectasis accompanied by lung opacities are typical of diseases with thick tenacious mucus and are the hallmark of cystic fibrosis o allergic bronchopulmonary aspergillosis. Coronal and axial CT confirm the presence of numerous central bronchiectasis, one of them with a large mucous impaction (C and D, arrows).

In the mediastinal window the impacted mucus is increased in density (E and F, arrows), which is a pathognomonic sign of ABPA.

Final diagnosis: ABPA with central bronchiectasis and dense pulmonary impaction
 
Congratulations to MG who was the first to answer and made a valiant effort to diagnose a difficult case.
 
Teaching point: this case looks difficult, but the diagnosis is easy if we identify basic findings. Discovering central bronchiectasis narrows the diagnosis to two entities and CT confirms one of them.