Dear friends,
Muppet was grumpy and decided to spent the Easter vacation in the Costa Brava (I suspect he had a secret date with Miss Piggy). He sent the above picture and the following case:
Seventy-five year-old woman, with pain in the back
Diagnosis:
1. Metastases
2. Lymphoma
3. Paget’s disease
4. None of the above
Seventy-five year-old woman, PA chest
Seventy-five year-old woman, lateral chest
Click here for the answer to case #17
The lateral chest shows an obvious ivory vertebra. The main differential diagnoses of ivory vertebra are metastases, Paget’s disease and lymphoma, and one of you even offered a reference (Muppet applauds Marius). Looking carefully, there is a second osteoblastic deposit in one of the lumbar vertebrae (arrow) and a third in the cervical area in the PA chest film (arrow).
These findings suggest metastases. Once the diagnosis of osteoblastic metastasis is considered, think of two organs: prostate in the male and breast in female. Looking at the breast shadows; the left one is missing. The telltale signs are the triangular shadow of the mastectomy in the soft tissues of the left hemithorax (arrow) and the decreased opacity of the left lower lung. Muppet is very surprised that none of you mentioned the absent breast.
Final diagnosis: osteoblastic metastases from operated breast carcinoma. Sagittal CT reconstruction confirms the findings.
Teaching point: always consider a rare manifestation of a common disease rather than a common manifestation of a rare disease. It works most of the time. In this particular case it would have lead you to search for the missing breast.
