Dr. Pepe’s Diploma Casebook: Case 59 – SOLVED!

Diploma_casebook_case59

Dear Friends,

This is the last case of the present term. I wish you all a very happy vacation. We will meet again in September.
The radiographs below belong to a 31-year-old man with vague chest pain. Diagnosis:

1. Aortic dissection
2. Aortic valve stenosis
3. Ascending aorta aneurysm
4. All of the above

Leave your thoughts and diagnosis in the comments section and come back on Friday for the answer.


q1

q2

Click here for the answer

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15 Responses to : Dr. Pepe’s Diploma Casebook: Case 59 – SOLVED!

  1. genchi bari italia says:

    ….delle tre opzioni suggerite, penso che , sulla base della clinica, si può escludere la dissezione aortica, prossimale, tipo A, perche’ la clinica sarebbe stata drammaticamente molto più imponente…l’aneurisma dell’aorta ascendente è rarissima in un soggetto giovane( 31 anni),…. rimane una stenosi aortica sopravalvolare, il che spiegherebbe il dolore e l’ipertrofia del ventricolo sx…come opzione alternativa ci potrebbe essere una destroposizione aortica(ma dovremmo avere altri sintomi clinici dovuti ad una eventuale azione compressiva sulla trachea -esofago)….la diagnosi finale è un “work-team” con il cardiologo x un Ecocardiogramma ed RM cardiaca….Saluti dall’Italia e da Bari x una serena estate!!!!!

    • genchi bari italia says:

      ….mi dispiace contraddirti dott.Pepe ma la risposta esatta , sulla base dei radiogrammi standard è la 2: stenosi valvolare aortica….infatti la stenosi valvolare aortica può essere congenita( valvola bicuspide) ma anche acquisita, su base reumatica….solo con Angiotc e/ o RM possiamo evidenziare il difetto valvolare congenito….sui radiogrammi standard dobbiamo “genericamente” parlare di stenosi valvolare aortica, senza specificare il sotto-tipo….Scusami…un abbraccio a te ed al “mitico”joseph !

  2. Maria says:

    I believe this is a right aortic arch case with maybe pressure on tranchea.

  3. Fares says:

    Diagnosis: Aortic valve stenosis.

    Explanation: There is enlargement of the ascending aorta + The left ventricle is enlarged too with mildly enlargede heart. In the same time there is no enlargement in the descending aorta.
    PS: May be there is some aortic valve calcification.

  4. Yaroslav Velychko says:

    2

  5. Fco Sarabia says:

    Parece existir dos anomalías en el el contorno de la silueta cardíaca y vascular, uno de ellos en el lado superior derecho que sugiere dilatación de aorta ascendente (sin poder diagnosticar aneurisma ni disección mediante Rx) y otro correspondiente a crecimiento de VI en el lado inferior izquierdo. Sumando ambos me inclino hacia estenosis válvular aortica.

    Por otro lado tronco pulmonar y arteria pulmonar principal izquierda no los consigo identificar con claridad. La radiografia PA podría estar un poco rotada aunque creo que es interpretable.

  6. Laurens says:

    As minority of patients with aortic dissection have only vague chest pain (and I suspect widening of right paraspinal line) I wouldn’t exclude possibility of aortic dissection. So in addition to dilated ascending aorta and aortic stenosis I choose option 4: all of above.

  7. Rajnee says:

    Aortic valve stenosis producing sitting duck sign

  8. gus says:

    My First choice is aortic valve stenosis us Fares says but we can’t easy exclude the other options so 4 All of the above.

  9. dim gr says:

    Translocation of the right paravertebral line, mild dilatation of the left ventricle and dilatation of the ascending aorta. I think aortic valve stenosis with dissection and mediastinal hemorrhage ( D. all the above).

  10. Dr. Pepe says:

    At this time of the day I believe I cal tell the right diagnosis. Patient had a bicuspid aortic valve with stenosis (correct answer). But the other two conditions also give dilatation of the ascending aorta in the plain film (second correct answer: all of the above).
    More information tomorrow. Wish you a happy vacation!

  11. Luigi Cocco says:

    Stenosi aortica.

  12. Muhammad wasel says:

    aortic valve disease

  13. Lena Manoli says:

    I saw the case late, after the revelation of the answer.
    Regarding the “sitting duck” sign, I found in the net that it is a sign for persistent truncus arteriosus in infants. Unfortunatelly I can’t copy-paste the image, but if you are interested here is the address where I found it;
    http://www.medicalgeek.com/pediatrics/23912-article-cyanotic-congenital-heart-disease.html

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