I feel we have been showing very difficult cases lately. To compensate, this week we are presenting an easy case of a 39-year-old woman, asymptomatic.
What do you see? Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.
Findings: the PA radiograph shows two small nodules projected over the anterior third ribs (A, arrows). Another nodule is seen at the lung base (A, red arrow) and there is a fourth one projected over the right scapula (A, yellow arrow). The lateral view shows a small nodule in the soft tissues (B, arrow).
Most of you mentioned accessory nipples because you saw only two symmetrical nodules. Noticing multiple nodules, some of them outside the lungs, suggests nodular skin lesions and brings to mind neurofibromatosis. Breast MRI nicely shows the false accessory nipples as well as other neurofibromas (C-D, arrows).
Final diagnosis: neurofibromatosis
Congratulations to Borsuk, who was the first to suggest the diagnosis
Teaching point: once again, avoid satisfaction of search. Although supernumerary nipples are the initial impression, finding other nodules leads away from this diagnosis and suggests a skin condition.
Skin nodules. Accessory nipples?
Aortic coarctation
Sorry to disagree. The artic knob looks normal and don’t see any rib norching.
Achalasia
Bilateral supernumerary nipples.
Supernumerary nipples
Mamas accesorias, bilaterales
Subcutaneous nodules. Accessory nipples demonstrated in lateral view
Tempted to say normal!
Are there scattered punctate calcific foci?
The two soft nodules over anterior aspects 3rd ribs are identical bilaterally.
Is there a lower lobe collapse??? Stumbling in the dark
Accessory nipples?
Acessory nipples
Nipple shadows n prominent and are higher in position than normal
Hello,
there are some lesions on skin. If it is a clue to diagnosis I suppose neurofibromatosis.
Accessory nipples
Did not see any widened foramina in lateral view for nf.
Is the tenting of l dome normal?
Foramina are OK. And diaphragm as well.
bilateral accessory nipples
…io penso, magico professore che le due piccole “opacità”, siano dovute ad indumenti,così pure quelle micronodularità di natura metallica.a dx….
And now, the million-dollar question. How many nodules do you see?
Maybe it is a low possibility , but can they be bone lesions? All nodules are at the same level with costae
There are multiple nodules. Distribution is both lateral inferior chest wall close to the and in the CP angles. Even in right and left hypochondrium regions. Bilateral upper lungs zones. Right scapular region. Bilateral neck area.
The diagnosis should be obvious now. Right?
ya of course neurofibromas!!
1 each overlying anterior aspects both 3rd ribs.
1 overlying Rt scapula.
1 anterior to upper sternum (lat view).
1 overlying rt 9th rib.
1-2 overlying liver.
?a cluster seen through stomach bubble.
1 or 2 at the back (lat view).
Small one above rt clavicle.
What do you think when seeing multiple nodules, some of them outside the lungs? Still stumbling in the dark?
.neurofibromatosi !!!! Goal !!!!!
Neurofibromatosis
Nf
Good!