Cáceres’ Corner Case 242 – SOLVED

Dear friends, welcome back!

Today I am showing a straightforward case to ease you into the new season. Promise I will not mention Covid-19 at all.

Today’s case is a pre op PA radiograph for knee surgery in a 47-year-old woman.

What do you see?

Come back on Friday to see the answer!

Click here to see the answer

Lung and mediastinum do not show any relevant findings. An isolated air-fluid level is visible in the left upper quadrant of the abdomen (A, arrow). The inner border of the cavity is smooth. The gastric bubble is visible under the left hemidiaphragm (A, red arrow).

Given that the patient is asymptomatic, an abdominal abscess or bowel obstruction/ volvulus can be safely excluded. A large intestinal diverticulum could be a possibility. I suspected a more mundane diagnosis: a review of the clinical history discovered that an intragastric balloon had been inserted fourteen months earlier.

Final diagnosis: air-fluid level in an intragastric balloon for morbid obesity
 
Congratulations to all of you who detected the air-fluid level. Kudos to Flemming Ghomsen who came close to the diagnosis.

Intragastric balloons for bariatric surgery may be filled with air or with saline. In the second case they may present an air-fluid level due to room air mixing during the injection of fluid.
 

Teaching points:


1. Remember to look under the diaphragm. You may discover interesting findings.
2. In your differential diagnosis always include iatrogenesis as a possible cause.

Musculoskeletal #9 – Flashcard

12-year-old boy, asymptomatic:

Radiograph a

Radiograph b

What do you see?

Lytic lesion on distal fibular metaphysis with well-defined sclerotic borders is seen on both anteroposterior (a) and oblique (b) radiographs

What do you see?

NOF: non ossifying fibroma

– 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

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.

Click here to see more images

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 218 – SOLVED

Dear Friends,

an easy case to celebrate the new year. PA radiograph of a 36-year-old woman with chest pain.

What do you see?

Click here to see the answer

Findings: PA chest radiograph shows a fracture of the right clavicle (A, arrow). A magnified view of the area raises the possibility of a lytic lesion (B, arrow).

Specific low-Kv images of the clavicle were taken, showing a rounded permeative lesion with a pathological fracture (C, arrow. D, circle). No other lesions were demonstrated in a bone scan. Biopsy followed by surgery came back as chondrosarcoma.

Final diagnosis: chondrosarcoma of clavicle with pathological fracture
 
Congratulations to Archanareddyt, who discovered the pathological fracture
 
Teaching point: when evaluating bone lesions of the chest, take specific views. They allow a better interpretation of the pathologic changes

Cáceres’ Corner Case 217 – SOLVED

Dear Friends,

I am showing today PA chest radiographs in two asymptomatic patients They have subtle findings that can be discovered if you paid attention to the previous webinars.

What do you see?

Prof. Cáceres will take some well-deserved holidays and will come back on January 6th with new cases!

Click here to see the answer

Case 1 findings: PA radiograph shows a well-defined opacity behind the cardiac shadow (A, arrow), better seen in the cone-down view (B, arrow). It has an extrapulmonary appearance and the best option is diaphragmatic hernia.

Coronal and sagittal CT demonstrate herniated abdominal fat through a rent in the posterior diaphragm (C-D, arrows).
 
Final diagnosis:Bochdaleck hernia

Case 1 has been diagnosed by most of you. Congratulations to Archanareddyt,
who was the first. Hope my recommendations in Webinar 4 were helpful!


REMEMBER

In the cardiac area look for:

* Opacities behind the left heart
* Double contour on the right

Case 2 findings: This patient has a faint but visible right infraclavicular nodule (A-B, arrows).

The nodule was overlooked and one year later had grown markedly (D, arrow). At surgery, a melanoma was found.
 
Final diagnosis: melanoma of the lung, missed in the initial examination

Teaching point: This is a difficult case, but easily diagnosed if you remember my oft-repeated mantra: “Search for pulmonary nodules in the pulmonary apices” (Webinar 1). Nobody saw the nodule and I feel useless (sniff).

Emergency #17 – Flashcard

40-year-old male:
* Fell off bike at 40 km/h
* Pain left shoulder

> What views of the shoulder in trauma setting should be done?
> Is this in endo- or exorotation?
> Do you need right shoulder to compare with?

Click here to see the images

Right shoulder for comparison

Additional trauma chest X-ray was done.

Differential diagnosis includes:

* AC-luxation
* CC-luxation
* Left pneumothorax
* No rib #

Dr. Pepe’s Diploma Casebook 151 – All you need to know to interpret a chest radiograph – Fifth Session – SOLVED!

Dear Friends,

Showing today the leading case of the next webinar. PA radiograph belongs to an 86-year-old woman with chest pain.
What do you see?

More images will be shown on Wednesday. You can refresh your memory viewing the older webinars on our youtube channel.

Dear Friends, showing today a lateral film of the case. Hope it helps.

Click here to see the lateral film

Click here to see the answer

Findings: PA radiograph shows a faint opacity in the left mid-lung field (A, arrow), better seen in the cone down view (B, arrow). The opacity is ill-defined, and my first impression would be an intrapulmonary lesion.

The lateral view shows that the opacity is located in the posterior chest wall. It has a typical pregnancy sign (C, arrow), indicating an extrapulmonary origin.
Enhanced axial CT confirms a low-density chest wall mass (D, arrow). Note the anterior displacement of the intercostal vessel (D, red arrow).

Final diagnosis: lymphoma of chest wall
 
Congratulations to all of you who diagnosed a chest wall lesion. Special mention to MK, who was the first to give the answer.
 
Teaching point: This case documents the importance of the lateral chest to clarify indeterminate findings in the PA radiograph.

Check the full webinar here

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.

Diagnosis:
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.

APPARENT PULMONARY DISEASE IN THE PA RADIOGRAPH, NOT SEEN IN THE LATERAL VIEW + CALCIFIED PLEURA IN THE LATERAL VIEW = CALCIFIED PLEURA SIMULATING PULMONARY DISEASE.

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.

FIRST CASE

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).

SECOND CASE

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