Caceres’ Corner Case 115 (Update: Solution)

ESR_2015_Blog-CaceresCorner-115

Dear Friends,

My good friend and former resident Romá Vidal sent me some images of a 39-year-old man with cough and moderate fever. Have a look at the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

Diagnosis:
1. TB
2. RUL collapse
3. Fungus ball
4. None of the above


lateral chest

PA chest

Click here for the answer to case #115

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    04
    May 2015
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    DISCUSSION 31 Comments

    31 Responses to : Caceres’ Corner Case 115 (Update: Solution)

    1. Rüdiger Worsa says:

      4, 4, 4, 4, 4, etc etc

    2. Ryan Tee says:

      On lateral film, if u follow the outline of the ‘upper lobe opacity’, you can trace the outline out of the hemithorax.
      So i think it is 4

    3. Andres Roca says:

      Yo creo es el numero 2, sin embargo por la clínica podría tratarse de un foco neumoníco sobrepuesto allí tambien

    4. Fares says:

      I think there is a pathology in the azygus lobe, may be a pneumonia

    5. Lola la Piconera says:

      I would say 4 Patient has an azygous lobe. There is a dense tubular structure following the azygous fissure as well that could represent a dilated azygous vein inside the fissure. Causes of this dilatation could be for example an anatomic abnormality or a pathological condition like IVC thrombosis in the venous retourn that shunts a lot of blood to azygous system. But this usually doesn’t cause cough nor fever….I can not see the cause of the fever unless as Fares says this tubular opacity corresponds to a pnaumonia.

    6. genchi Bari Italia says:

      ….l’opacità’ e’ di pertinenza della scissura da v. Accessoria lobo azygos…..quest’ ultimo e’ normo trasparente ed indenne….la patologia e’ della pleura…..lipoma o tumore fibroso della pleura(dd con TC)…..saluti da Bari…..ed attenti a Vidal, quello della Juve….e’ un terrore X le squadre avversarie…..arrivederci a …..Londra !

    7. cocotet says:

      A consolidation in the azygos lobe?

    8. Iffat Rehman says:

      4, azygous lobe pathology, most likely a pneumomic consolidation. Consolidation tends to be denser outlining the fissure. D/d encysted fluid in azygous fissure. Azygous vein enlargement is usually more subtle, medially and the patient will not have a history of fever. Comparison with prior film if possible, will be helpful. If not, will recommend follow up cxr after appropriate antibiotic therapy.

    9. tekwani parmanand says:

      TB

    10. murzin says:

      Loculated pleuropneumonia in the accessory azygous lobe…

    11. Amir parsa says:

      I think none of the them is correct acording these ,
      1, both hemidiaphragm and both hillum at normal it show no decrease in lung size.
      2. No mediastinal , tracheal devetion it show no volume loss in RUL and no collaps.
      3.no LAp was shown, in pA And LAT ,
      I think its an azygus lobe ,,

      • Yvette says:

        I agree with Amir in point 1 and 2. There is no corresponding changes on lateral view. But is there an opacification in the retrotracheal triangle? Posterior tracheal line a bit wider? I also think about structures coming from posterior mediastinum like duplication cyst, vascular anomalies,neural tumors or diverticuli.
        This is a very difficult case Dear Doctor.
        I am looking forward to your answer. ☺

        • Jose Caceres says:

          Actually, it only looks difficult. Analize the image and the answer is obvious. Don’t give up!

    12. Amir parsa says:

      Although a small density was show at LAT weiv ant port of T4 vertebra can be a fungal ball…..but i am not sure

    13. ays says:

      Golden S sign

    14. gus says:

      Could be a normal variant (azygus lobe type A trigonum parietale lateral in pulmonary apex ) but because the patient symptoms consolidation is the first thinking.

    15. Lola la Piconera says:

      By the way Dr Caceres, all your former residentes looks like your self and the mupet as much as Dr Roma Vila does?

    16. Ramesh Pandey says:

      Dear Sir
      Greetings
      Looks like option 4 as pathology seems to be consolidation involving Azygous lobe…mimicking positive cervico thoracic sign

    17. I thank that it is consultation in the right upper lobe apical segment with cavitary changes associated with multiple hilar LNS – TB is my first choice

    18. genchi bari italia says:

      ….grazie mitico blaugrana professore per i saluti portatemi dal mio amico e collega dr Florio , Bari, da Davos….sono veramente onorato di tutto questo…..spero di incontrarti di persona , magari a Barcellona….per il caso in oggetto devi comunque convenire che in una DD ci poteva stare anche la mia diagnosi….Incredibile MESSIIIII !!!!!

    19. Gela says:

      Hai I’m doctor gela fron the Philppines i can see the real X-ray of the heart

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