Dear Friends,
Welcome back! To start the academic year I would like to show a case seen by Dr. Pepe while I was vacationing in Minorca.
Radiographs belong to a 35-year-old woman with pain in the mandible for the last two years. CT of the mandible before biopsy and pre-op PA chest radiograph are shown. After seeing both, Dr Pepe suggested a diagnosis. What do you think?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
CT mandible
PA chest
Findings: CT of the jaw (A) shows multiple lytic lesions, initially suspected to be a local tumor (adamantinoma). Pre- biopsy PA chest shows several small nodules in the upper lungs (B, circles).
The combination of lytic bone lesions and nodules in the lung raised the suspicion of Langerhans -cell histiocytosis. The referring physician was contacted and an immediate CT was performed, showing numerous small lung nodules, the majority of them with cavitation (C, D). This appearance is highly suspicious of histiocytosis. Diagnosis was confirmed with bone biopsy. Referring physician was very impressed.
Final diagnosis: Langerhans-cell histyocitosis of lung and jaw.
Congratulations to GH and UFTM radiogroup for their early diagnosis
Teaching point: always look carefully at pre-op chest films. If interpreted correctly, they may facilitate the diagnosis.
….pregiatissimo Professore, displasia fibrosa della mandibola ed opacità micronodulari al polmone sono suggestive per sclerosi tuberosa e linfangioleiomiomatosi….un saluto, in abbraccio…..
Welcome, old friend!
To early to offer a comment. Wait till Friday
Histiocytosis LCH
Paget’s disease
Hi, Profesor, welcome back!!
There are some nodular lesions in pulmonary apices and lytic lesions in mandibule. We think in Histiocytosis LCH. Is this person a smoker?
Yes, she is a smoker.
Welcome back!
Could be unusual case of sarcoid though? lytic bony lesions and some pulmonary nodules..
Whenever I look a this case, cannot stop thinking about gorlin goltz syndrome.
I know it is neither common nor highly testable stuff and we shall all go for the most common first but the history of the young lady makes me actually think so..
Is there a spina bifida th1 Professor? Dont see well on the cell phone..if yes thats my gorlin then. However , lets just forget the suspected finding, I could be wrong. I only wanna say that – Someone could even show us a picture of a zara t- shirt, after such history, this syndrome should be somewhere on our differential list anyway. Thats my last comment I promise as I do not want to take the whole floor.
Glad to have yu back!
Yes, she smokes
It´s great to have you back, professor!!
So it is not the Gorlin Syndrome? It is super cool case I think. Thank U.
ovoid and elliptical subcortical, well-defined, lytic lesions in the mandible combined with reticulo-nodular opacities in the lung apices in an otherwise normal lung x-ray.
LCH would be a good diagnosis as the patient is a smoker, keeping in mind multiple myeloma and paget`s disease.
best greetings from austria, professor…
Greetings from Minorca (short vacation)
Patient is too young for myeloma and Paget, don’t you think?
Greetings from Minorca (short vacation)
Don´t you think thet the patient is too young for myeloma and Paget?
hm, of course both entities are of higher age in general…
As far as I remember, Gorlin’s does not affect the lung. It’s a nice diagnosis, though
Would it be fine to add an unusual manifestation of sarcoidosis of mandible and sarcoid lung to our ddx list? I ve seen a gorlin syndrome with lung mets once but now I see this one is not the case. Is that LCH path – proven already? Superwork Professor.
Your opinions are welcome and enrich the discussion. Don’t see any spina bifida. Anyway, non-united posterior neural arches are not uncommon and are non-specific.
I would expect sarcoidosis to have enlarged lymph nodes at this stage. Or else, fibrosis with hilar retraction.
In summary: if you hear hoofbeats, think horses, no zebras 😉
Got it, we shall go for the most common and everything would rather be a common horse until proven otherwise. Uncommon zebras as ddx of exclusion. And a holiday on Minorca would be a good idea for all those who think zebras, no horses 😉
I think Langerhans Histiocitosis is a good diagnosis because of a lytic lesion in the mandible angle. In the PA rx I see an enlargement of the lower portion of the vascular hilum and a intersticial thikening in the upper lobes wifi a nodule in the URL.
I agree. Answer on Friday
Histiocytosis