* Since 1 day periumbilical pain radiating to RLQ.
* CRP 75, leucocytes 18.000.
What do you see? Appendicitis? Diverticulitis?
presenting chest radiograph of a 77-year-old man with malaise and weight loss.
What do you see?
This is the last case before the summer. Will see you again in September. Enjoy your vacation!
Findings: PA radiograph shows increased opacity of the left hilum (A, arrow), which is due to a mass projected over it, as seen in the lateral view (B, arrows). In addition, there is convexity of the aortopulmonary window (A, red arrow)
The increased hilar opacity (C, arrow) was not visible in a PA radiograph taken six months earlier (D, circle). Convexity of the aortopulmonary window (C, red arrow) was not present at that time.
In the lateral view, the mass (E, arrows) was visible six month earlier, albeit smaller (F, arrow). This progression indicates rapid growth.
Enhanced axial and coronal CT confirms a pulmonary mass invading the aortopulmonary window (G and H, arrows). Lung metastases were present (insert, red arrows)
Diagnosis: lung carcinoma invading the aortopulmonary window
I am presenting this case to discuss the aortopulmonary window (APW), which is a small mediastinal space located between the aortic knob and the pulmonary artery in the PA view (Fig 1A). The APW is normally concave; convexity (Fig 1B) suggests an abnormality that should be studied with enhanced CT.
Visibility of the APW is difficult in the elderly, because the superimposed uncoiled descending aorta makes the interpretation more difficult (Fig 2).
Convexity of the APW may be overlooked unless we look specifically at the area (fig 3). The larger the abnormality, the more readily it is detected in the chest radiograph. Subtle changes are more difficult to identify and comparing with previous films is very helpful.
Causes that may alter the APW are: tumors, enlarged lymph nodes, aortic aneurysms and increased mediastinal fat. The phrenic nerve crosses this space and a phrenic neurinoma may also grow in the APW, although I have never seen a case.
Enlarged lymph nodes are by far the most common cause of occupation of the APW. They may occur in malignant and non-malignant diseases. They usually coexist with radiographic manifestations of the primary process (Figs 4 and 5).
In isolated occupation of the APW the etiology cannot be determined in the chest radiograph and enhanced CT should be obtained (fig 6).
Aortic aneurysm is an uncommon cause of convexity of the APW (Fig 7). The abnormality is initially subtle and it becomes more evident as the aneurysm grows (Fig 8).
Radiographs taken five years earlier did not show the abnormality (E and F, circles).
Enhanced axial and coronal CT demonstrate that the mass represents a saccular aneurysm arising from the aortic arch (G and H, arrows).
Comparison with previous films shows a normal APW in 2007 and progression of the opacity over a three-year period (arrows).
Enhanced CT shows that the opacity represents a partially thrombosed aneurysm arising from the inferior aspect of the aortic arch (C-D and E, arrows).
Last but not least, we should remember that mediastinal fat is an innocuous cause of convexity of the APW (Fig 9).
Follow Dr. Pepe’s advice:
1. Convexity of the APW suggests underlying pathology.
2. Enlarged lymph nodes are the most common cause of a convex APW.
3. Aneurysm and mediastinal fat may also enlarge the APW
We present the case of a 31-year-old woman with:
* Nausea and vomiting since three days
* Unable to eat or drink without vomiting
* Epigastric pain after eating
* Feels weak
* No prior trauma or illness
* No fever, no diarreha, no hematemesis or bloody stools
* No other family members ill
See below the laboratory findings:
What do you think?
Signs of dehydration with secondary acute renal impairment and electrolyte disorders
Abdominals X-Ray were performed:
What do you see on the X-Rays?
* Apparent elevation of the right hemidiaphragm with obscuration of the right cardiac border
* Air – fluid level at the right upper quadrant: free air?
* Colonic air at the right upper quadrant (Chilaiditi)
* Apparent soft tissue mass at the right upper quadrant
* No apparent dilated bowel loops
* Elongated right liver lobe (Riedel lobe)
* Instability of the symphysis pubis
* Subphrenic abscess
* Hepatic abscess
* Anterior interposition of colon to the liver
* Loculated pneumothorax (mimick)
* Situs inversus – gastric air (mimick)
* Pneumobilia, portal venous gas (smaller amount)
Images from an abdominal CT-scan:
What do you see on the CT images?
* Anterior defect in the right hemidiaphragm
* Partial herniation of stomach and transverse colon
* Gastric outlet obstruction due to compression of the pyloric region of the stomach, with secundary dilatation with fluid
* Normal position of the gastro-esophageal junction and hiatus
* No signs of ischemia
* Collapse of the right middle lobe and partial collapse of the right lower lobe.
What is the most likely diagnosis?
Morgagni hernia of the diaphragm
Patient had a laparoscopic reduction of the hernia with mesh closure of the defect. No signs of ischemia at surgery.
Uneventful recovery with resolution of pain and normal intake the day after.
* Rare congenital diaphragmatic hernia (<5% of all CDH)
* Anterior (retrosternal)
* Right-sided (90%)
* Usually small
* +/- 30% symptomatic: respiratory distress (newborn), recurrent chest infections, abdominal symptoms
* Contents: omental fat, transverse colon (60%), stomach (12%)
* Treatment: surgical repair
> In symptomatic cases, some say also in asymptomatic cases: prevention of strangulation of hernia contents
* Differential diagnosis:
> Traumatic diaphragmatic rupture
> Diaphragmatic eventration / weakness / paralysis (abnormal contour / position of the dome)
> Cardiophrenic angle lesions ( pericardial fat pad, cyst, lipomatosis, tumor)
Today I am presenting a case given to me by my good friend José Luis López Moreno. The PA radiograph belongs to a 77-year-old woman with pain in the right hemithorax.
What do you see?
More images will be shown on Wednesday.
showing today axial and coronal CT.
What do you think?
Findings: PA radiographs shows an ovoid opacity in the right lung (A, arrow), that parallels the path of the anterior ribs. Careful observation demonstrates that the third and fifth anterior ribs are visible (B, red arrows), whereas the anterior fourth rib is absent (B, asterisks). An additional finding is moderated flattening of D11 and D12 (A, circle). The findings suggest multicentric bone lesions.
Enhanced axial and coronal CT confirm a lytic expanding lesion of the anterior fourth rib (C and D, arrows), better seen in the 3-D reconstructions (E and F, arrows).
In an adult, lytic expanding rib lesions are usually either metastases (thyroid, renal cell carcinoma) or multiple myeloma. Further studies confirmed a myeloma.
Final diagnosis: multiple myeloma affecting the right fourth rib and several thoracic and lumbar vertebrae.
Congratulations to Wafaa who suggested the diagnosis in the plain film and to VL who discovered the collapsed vertebrae.
Teaching point: remember to look at the underlying rib when facing a pleural/chest wall lesion. An affected rib will narrow down your diagnostic options. And don’t forget satisfaction of search (collapsed vertebrae in this case).
This case belong to the section “The wisdom of Dr. Pepe”, in which an (useful?) aphorism ends the presentation.
I am presenting a routine PA radiograph in an asymptomatic 79-year-old woman operated on for a breast DCIS five years ago. PA radiograph taken five years earlier is shown for comparison. More images will be shown on Wednesday.
3. Primary lung tumor(s)
4. Any of the above
showing CT images with and without contrast enhancement.
What would your diagnosis be?
2. Active TB
3. Fibrous lung tumor
4. Any of the above
Findings: The PA chest radiograph shows two obvious small nodules in the left middle lung field (A, circle), not present five years earlier (B). In my experience, two nodules close together are usually granulomas. But in this case we have another finding: a subtle bulge in the left hilum (A, arrow), not visible in the previous film, highly suspicious of hilar adenopathy. This changes the diagnostic orientation and makes us think of an active process.
Unenhanced axial CT shows an hourglass-shaped pulmonary lesion (C and D, arrows) that simulated two nodules in the chest radiograph. The lesion enhances after contrast injection and contains a large arterial vessel (E, arrow). Non-enhancing lymph nodes are visible in the left hilum (F, arrow).
Although all three diagnoses offered in the blog can cause hilar adenopathy, the vascularity of the lesion points to a tumor.
PET-CT shows faint uptake of the primary lesion and the hilar lymph nodes (G and H, arrows). A needle biopsy (I, arrow) came back as an atypical small-cell tumor.
The patient was treated with chemotherapy and radiotherapy, with a good response of the primary tumor (J, arrow) and lymph nodes (K, circle).
Final diagnosis: SCLC with hilar metastasis and a good response to QT and RT
Discussion: I just finished reading “The subtle art of not giving a f*ck“ and there is an enlightening (and sadly true) chapter entitled “You are not special”. In this particular case I was feeling special, as I diagnosed a malignant pulmonary fibroma based on a single case seen 20 years ago (see below) because of the similarity of the vascular pattern in the two cases. After 50 years of practice, I forgot a basic principle: common conditions are, well, common. I’m showing this case to remind you that when faced with a diagnostic dilemma you should first consider common options rather than uncommon ones.
To redeem myself, I am showing my only case of fibrous tumor of lung in a 37-year-old woman with hemoptysis. The PA radiograph shows a well-defined paramediastinal nodule (A, arrow). Enhanced coronal and sagittal CT confirms the intrapulmonary location of the nodule, which has a large arterial vessel in the center with an aneurysm at the end (B and C, arrows).
Two bits of information about fibrous tumor of the lung: It is a very unusual spindle-cell tumor with the same histology as fibrous tumors of pleura, and like them, it has malignant potential. It is usually asymptomatic and is seen as a rounded or ovoid nodule of varying size. Immunohistochemistry is important for the diagnosis.
Follow Dr. Pepe’s pearls of wisdom:
Always consider that what you are seeing is a rare manifestation of a common disease rather than a common manifestation of a rare disease.
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?
Findings: PA chest radiograph show numerous metallic wires spread fan-like throughout the upper two thirds of both lungs.
This appearance is typical of endobronchial coils for lung volume reduction in patients with emphysema. They are used when other therapeutic alternatives are not feasible or as a bridge to lung transplantation.
I am showing this case because I have never seen one and wanted to share it with you. And to complain about the last season of Game of Thrones, of course!
Congratulations to all of you who made the diagnosis, led by MK, who was the first.
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.
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).
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.
Enhanced axial CT shows the markedly collapsed lobe (C, arrow). Coronal CT depicts a mass obstructing the LLL bronchus (D, arrow). Final diagnosis: carcinoma.
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).
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
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).
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).