Caceres’ Corner: Case No. 21 (Update: Solution)

Dear Friends,

Muppet promises never again to show a bone case. He has been severely reprimanded!

Back to good ol’ chest imaging:

29-year-old male heavy smoker. Admitted with mild dyspnea.

Diagnosis:

1. Mediastinal tumour
2. Dilated cardiomyopathy
3. Pericardial effusion
4. None of the above

29-year-old male, heavy smoker

29-year-old male, heavy smoker

Click here for the answer to case #21

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15
May 2012
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DISCUSSION 34 Comments

34 Responses to : Caceres’ Corner: Case No. 21 (Update: Solution)

  1. Alice says:

    1. Mediastinal tumour

  2. Vilma says:

    Mediastinal tumour and pericardial effusion.

  3. Marius says:

    Well, back to chest… bone is no fun- it’s all about experience there; plus no good books under 5-volume-sets.
    So i see the X-ray is carefully blackened so as not no see signs of vascular redistribution; or is it so as to show the peculiarly rounded inferior right cardiac border ? Anyway: the heart enlargement seems bottle shaped (but on profile the epicardial fat pad is not displaced), overlaps pulmonary hilli without {visible} pulmonary vessel enlargement. I see also a septal thickening in the left pulmonary base (Kerley B?) but no pleural effusion. I see no signs of cardiac failure. Apex of the heart is ascended and inferior left cardiac arch is rounded. So i won’t go with pericarditis, but with a right heart enlargement (that goes with smoking) + maybe a pericardial cyst ? I’d have a echo than CT to diagnose.

    • Jose Caceres says:

      Muppet concerned abot the few answers. Is he losing the favour of his followers? Case too easy/difficult?
      Hint: look at the lateral view

  4. Gyan M says:

    Tumor, mass or cyst. Pericardial cyst?

  5. Albert says:

    Enlargement of the heart shadow that hides the hila related to pericardial effusion.
    Occupation of the retrosternal space on tha lateral view suggesting a possible anterior mediastinal mass.
    The pericardial effusion doesn’t allow to asses the hila on tha AP, but on the lateral view is possible that the left pulmory artery shadow was enlarged and nodular (especially in its craneal part where seems to be two nodular spiculated opacities). Then also seems to exist occupation of subcarinal space giving the “donut”sign. That suggest extensive adenopathies.
    I propose lymphoma (anterior mediastinal mass and extensive adenopathies) with pericardial effusion.

    • Jose Caceres says:

      Better late than never! But Muppet disagrees with some parts of your comment. Other that the shape of the cardiac shadow (unreliable finding) you don’t have any criteria to diagnose pericardial affusion.
      Aside from this, good discussion

  6. MAK says:

    Globular shape enlarged cardiac shadow,pericardial effusion.
    Loss of retrosternal Lucency likely mass in the anterior mediastinum.
    Opacity with irregular margins in the upper zone.
    Hyper translucent lung fields.

  7. Gyan M says:

    A diagnosis Anterior mediastinal mass cannot be challanged. However possibility of spring water cyst should also be considered. Lateral view clearly shows anterior mediastinal opacity. Further evaluation with CT thorax needed.

  8. maRIA cLAUDIA pULIDO says:

    La silueta cardiomediastínica está muy aumentada en la proyección PA y en la lateral se observa una ocupación del espacio retroesternal, lo que me sugiere una ocupación del mediastino anterior. Diagnóstico diferencial: 4 Ts….

    • Jose Caceres says:

      There are only 3 Ts: thymoma, teratoma and “terrible lymphoma” The fourth T (thyroid) belongs in the superior middle mediastinum. All according to the Muppet, who is nearly infallible!
      Good discussion. Muppet awed

      • maRIA cLAUDIA pULIDO says:

        I agree thyroid belongs to the middle mediastinum most commonly, but i wouldn´t exclude it from the anterior mediastinum.
        PS: finally i got the right answer!! mediastinal tumor! 🙂

  9. yasir jamil khattak says:

    1) Globular heart shadow occupying more than half of the thorax, goes with pericardial effusion.
    2) loss of normal anterior mediastinal lucency, yes it could be lymph nodes but then the frontal view doesnt support it much ?
    3) lateral view shows abnormal density projected over the heart shadow , again raising the possibility of a mass.
    4) lungs clear, TB less likely
    so i’ll go with pericardial effusion. second possibility is dialated cardiomyppathy.
    fingers crossed and WAITING for muppet to break the shackles !

    • Jose Caceres says:

      Sorry, Muppet walked close to kryptonite, shackles will stay for a while longer.
      You are in for a dissapointment, though.It’s not what you think. Answer coming soon.

  10. Riccardo says:

    Mediastinal lipomatosia

  11. thea says:

    rodis iqneba swori pasuxi?

  12. riccardo says:

    mediastinal lipoma/liposarcoma

    • riccardo says:

      I posted the answer and nobody considered it!

      • Jose Caceres says:

        Sorry. Muppet recognizes your contribution. But it will be unfair to the other participants to give away the answer too early. From now on, when anybody makes the right diagnosis Muppet will tell him/her on the private mail.

  13. faidra says:

    looking only at the pa film I would have started the differential diagnosis for an enlarged heart. interestingly on the lateral film, there is opacification of the retrosternal space indicating an anterior mediastinal mass. 3 Ts for diagnosis, I agree.

    any signs on the pa that indicate that this is not enlarged heart?

    • Jose Caceres says:

      No signs in PA. Lateral view helps to diagnose mediastinal masses and pericardial fluid

  14. Mohammed Noeman says:

    I think it is a mediastinal Tumor (for example: Thymoma or Thymic Caner).
    Iam not sure, but i think you showed us a similar case in the lecture of Mediastinum in ECR2012 🙂

  15. GENCHI BARI ITALIA says:

    nON è UNA MIOCARDIOPATIA Nè UN VERSAMENTO PERICARDICO, PERCHè LO SPAZIO RETRO-CARDIACO è LIBERO( VEDI L.L.)E NON CISONO SEGNI DI SOFFERENZA DEL PICCOLO CIRCOLO, TRANNE UN PICCOLO VERSAMENTO PLUERICO NEL SENO COSTO-FRENICO SX. nON è UN TUMORE MEDIASTINICO PERCHè LA LA MASSA ABREBBE CONTORNI IRREGOLARI E CI SAREBBE UNA CLINICA DI INGOMBRO MEDIASTINICO. SAREBBE ALLORA LA 4 IPOTESI DI UNA PSEUDO-MASSA A PARTENZA DAL MEDIASTINO ANTERO-SUPERIORE CHE IN L.L. è OPAco: penso allora ad una cisti timica( la TC ne confermerebbe il contenuto liquido)

  16. Thymoma for me would be the first diagnosis subjectively there is a slight wavy but how does smoking fit in? May be incidental?

  17. Luigi Cocco says:

    Pericardial effusion.

  18. joe says:

    Podria ser Cardiomiopatía dilatada, garcias al consumo exesivo de sustancias toxicas, quimicas y peticidas que contiene el tabaco

  19. Mario Petrillo says:

    Pericardial cyst???? 4ts (CT is needed…)

  20. wouter says:

    endocardatis fommowing pneumonia?

  21. Adriana Barreiro says:

    3 Ts or mediastinal fat.

  22. GENCHI BARI ITALIA says:

    Illustre collega come vedi dal mio commento,ho indovinato la patologia come di pertinenza timica: non si poteva dewfinirne il contenuto se non con la TC (cisti timica v-s timolipoma):non pensi allora che sia stato bravo? Perchè non ha commentato la mia risposta? Non conosco ben l’inglese ecco perchè mi sono espresso in italiano!

    • Jose Caceres says:

      Sorry. No problem with writing in Italian. Muppet gets by in several lenguages.
      Muppet congratulates you for being right

  23. GENCHI BARI ITALIA says:

    Grazie per le tue belle parole!!!!!

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