José Vilar and Friends Case 7 (Update: Solution!)

Good day colleagues,

This case was brought to me by Drs María Vega, Magdalena Graells and Luis Garcia (Hospital Universitario Dr Peset, Valencia; all pictured above in the case cover) and opens a new look to my blog.

This is a 35-year-old man from Pakistan that complains of long standing back pain.

We start with a chest radiograph. Please look carefully at the images and tell me what you think.

Update: Additional images and comment!

Pancoast it’s a good choice when you see a lesion like this, but this patient is a bit young for a diagnosis of lung cancer (but not impossible). Here are several CT images that may help in the differential diagnosis, and explain the back pain.

Click here for the answer




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    01
    Apr 2019
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    DISCUSSION 11 Comments

    11 Responses to : José Vilar and Friends Case 7 (Update: Solution!)

    1. NAIF SALEH ALQAMAF says:

      no abnormality detected .

    2. Krister Askaner says:

      Apico-dorsal pleural thickening. Scalloping of right 4th rib

    3. Krister Askaner says:

      Apical posterior pleural thickening with scalloping of right 4th rib

    4. SUBBARAO KAKARLA says:

      Pan coast tumor.

    5. Krister Askaner says:

      Beside rib scalloping and pleural thickening there is an associated posterior soft tissue swelling.

    6. Mk says:

      Hello!! There is an increased density projected over the upper right lobe. In the lateral view, it seems to be extrapulmonary and I can delimitate the 4 posterior costal arc in the PA view so I think it is a costal lesion.

    7. Trinity says:

      Chest X ray PA view shows poor delineation of the posterior end of the right 3rd rib with a peripheral based homogeneous opacity in the RUL. No evidence of air fluid level, calcification or cavitation noted within the lesion . At least two linear reticular opacities are seen in the paracardiac region on the right side parallel to the right hemidiaphragm. No other pulmonary opacity see. A few radiopaque densities are seen in bilateral hila -may represent calcified hilar lymphadenopathy.
      Cardiac and hemidiaphragm silhouette normal. No other bony or soft tissues abnormalities seen.
      D/D 1. pleuropulmonary TB with bony involvement
      2. Pancoast tumor.

    8. Krister Askaner says:

      Rib destrucrion and destruction in posterior element of vertebra S1. Associated granulomatous soft tissue swelling. Extrapulmonar TB? TB osteomyelitis?

    9. VL says:

      Chest Xray PA view reveal lesion involving right posterior fourth rib . Uninvolved part of rib shows narrow zone of transition and my differential at this stage would be rib lesion like FD, LCH and Osteoblastoma. Other differential based on chest X-ray would be pleural based mass like solitary fibrous tumour , metastases or chest wall based mass like neurofibroma. However, on CT chest lesion appears to be entered within pleura and appears to be secondarily involving bone . Underlying rib appears sclerotic, dirty like chronic osteomyelitis picture . In the sacrum lesion shows peripheral thick enhancement and central cystic area ,is extending into canal and displacing thecae sac to right side . Underlying right lamina is not seen.

      Considering both lesions and young age of patient my top differential would be a chronic infective process like tuberculosis . Brucellosis has to be kept in mind considering that theses masses appear well localised. LCH is another differential in young people. Considering the age and no history of primary metastases should not be differential.

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