Caceres’ Corner: Case No.8 (Update: Solution)

Dear Friends,

Here is case number 8:

Sixty-three year old male admitted to the Emergency Room with possible pulmonary embolism. Chest radiographs show a bulge in the descending aorta. Enhanced CT from the apex of the lungs to the diaphragmatic domes confirms the embolism. A more caudal axial CT shows a rounded opacity surrounding the aorta.


1. Neurofibromatosis
2. Lymphoma
3. Cystic lymphangioma
4. None of the above

Muppet is very frustrated about the previous case. He thought you would all diagnose it easily and says that if you don’t get the new one, he will retire to a nunnery…

63 year old male, PA chest

63 year old male, PA chest

63 year old male, chest CT

63 year old male, chest CT

63 year old male, enhanced CT

63 year old male, enhanced CT

63 year old male, caudal CT

63 year old male, caudal CT

Click here for the answer to case #8

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    Dec 2011
    DISCUSSION 37 Comments

    37 Responses to : Caceres’ Corner: Case No.8 (Update: Solution)

    1. drraishu says:


    2. Mohammed Noeman says:

      The axial CT-scan of the Thorax shows multiple infracarinal lymphnodes enlargement.
      The second slice shows a paravertebral mass in the posterior mediastinum. The mass is of soft-tissue density and is surrounding the descending aorta without invasion of the visceral pleura (preserved fat plane). However, I suspect pressure effect on the vertebral body. There is no cystic degenerations or necrotic areas.
      My DD would be:
      1- Neurofibroamtosis.
      2- Lymphoma
      3- Extramedullary hematopoiesis

      • Mohammed Noeman says:

        I would like to perform a CT-guided biopsy through parvetebral approach to confirm the diagnosis 🙂

    3. Dimitris K says:

      Neurofibromatosis would be possible,but the mass shows no enhancement so extramedullary hematopoiesis

    4. Ieva says:

      Because of PE in presence of no other risk factors

    5. Marius says:

      Based on those images – Lymphoma. Because masses are confluent and PTE. Futher dx needs more images.

    6. girish kulkarni says:

      -Widening of left paraspinal line with lobulated retrocardiac opacity on chest radiograph with widened lower right paaratracheal stripe.

      -CT chest showing pulmonary embolism with left paravetebral soft tissue with precarinal and retrocardiaac lymphadenopathy.

      Lymphoma should be the first possibility.
      Extramedullary hematopoiesis and mediastinal hematoma are other differentials but there is nothing in the history or on images to suggest these diagnoses.(presuming that thin linear structure seen in the descending thoracic aorta is artefactual,and not an intimal flap!)

    7. Vyzantios P says:

      Extramedullary hematopoiesis would have know clinical history.. But the combination of enlarged lymph nodes i believe suggests lymphoma..

    8. Marius says:

      You’re cheating.. Scout is a (very very) devious way to show splenomegaly.. it is by far contextual as a finding on a scout, as there are other causes for lack of stomach air bubble. Given the fact you pushed splenomegaly, retrospectively that would cause trombocitopeny and PTE, so this plus splenomegaly would fit chronic myelogenous leukemia.

      • Marius says:

        I have NEVER imagined i could diagnose CML on a chest X-ray. My humble respect, professor.

        • Jose Caceres says:

          Thank you. My objective is to make you think and consider alternative diagnosis, other than the obvious ones. Yours is a good diagnosis; but still not the right one.
          Wil give you a hint: why is the azygos vein enlarged in the PA chest film?

          • Marius says:

            Bummer.. I’ll give it one more shot. Budd-Chiari syndrome? What really bothers me is that para-aortic mass does not really fit a lymph node station – there is none there (between pleura and descending aorta); i’ve first said lymphoma because of encasing character. Are those some collaterals in azygos/ hemiazygos system?

      • Jose Caceres says:

        The air bubble is present and displaced towards the right. That, and the opacity in the left upper quadrant suggests splenomegaly.
        I am not cheating. Muppet is 😉

    9. Anna says:

      I vote for four! Greetings for Mr. Muppet.

    10. Sabra says:

      The soft tissue surrounding the descending Aorta is an abnormal juction probably between the Hemiazygos and azygos vein, witch are clearly enlarged.
      These foundings could suggest an obstructive proces of the inferior vena cava and probably a neoplastic proces in the abdomen- liver?

    11. amutha says:

      thoracic splenule

    12. amutha says:

      can be loculated pericardial/pleural fluid

    13. amutha says:

      Left sided IVC with hemiazygos continuation

    14. aca says:

      Deep veins thrombosis,Neo pancreatis?paraneo sy.?
      IVC thrombosis and Cavo-caval anastomosis-shunt true azygos-hemiazygos system…other diagnosis consider esophageal varices in cirhosis,but there is no signs of superficial colaterals-caput medusae?splenomegalia is present…maybe meta in hepate,or other some short-term pathology?
      No hereditary vascular malformation,no evidence of colaterals

      • Jose Caceres says:

        OK, after the azygos tip, you all are close enough. Will give you a collective A! ( Muppet wanted to scale it down, but I stayed firm). Wait for the final answer.

    15. o s alnuaimi says:

      now it is clear that there is a process of venous shunt through azygos system , but what about the translucent line retrocardiac , is it the esofagus displaced laterally by something which also obstruct the IVC ? the fact o splenomegaly and these shunts let us think about a problem that needed time for all these modifications to appear , and the association of pulmonary embolism again let us think about systemic cause of general dissiminated thrombosis , i agree with the idea of paraneoplastic sdr. regarding the age of the patient , thrombosis may be also involve the supra hepatic veins and this is the Budd Chiarri sdr. ?? .

    16. Sara says:


    17. A.W. says:

      Retroperitoneal fibrosis causing portal vein hypertension – therefore as a consequence – a dilated azygos and splenomegaly.

    18. Ieva says:

      This was the best case of all!!! Happy 2012!

    19. o s alnuaimi says:

      wonderfull case

    20. zena dawood says:

      Oesophageal varices ..dilated azygous vein secondary to portal hypertention ..with retrocardiac mass …represent oesophageal varices.