I am doing spring cleaning of my cases and this week I am showing two of them. Radiographs belong to two unrelated middle-age patients with chest pain.
What do you see?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
Case 1 findings: PA radiograph shows an extrapulmonary lesion at the periphery of the right hemithorax (A,B arrows). Those of you that diagnosed a rib fracture are very perceptive, because I did not see it.
The patient was recalled and a CT showed disappearance of the extrapleural haematoma and the callus from the healed fracture (C-D, arrows).
Final diagnosis: acute rib fracture with extrapleural hematoma
Case 2 findings: Chest radiograph shows a sclerotic right 6th rib (E, arrow). The appearance of the rib suggests a benign lesion, supported by a previous report five years earlier (no radiograph, sorry) in which the sclerotic rib was described.
In my opinion, the facts that the rib is enlargedand and the sclerosis reaches the distal ends, and the thickened cortical, point to Paget disease.
Final diagnosis: probably Paget disease of the 6th rib (unproven)
Congratulations to the majority of you who suggested the right diagnosis. To me you are all winners.
Teaching point: fracture is the most common rib lesion. It should be our first diagnosis even if the findings are not clear, as you proved in this case.
In the firts one, there are at least two left costal fractures (pathologic vs traumatic) and a nodular lesion at the right 8 costal arc probably extrapulmonar (chronic fracture?)
In the second one, the right 6 costal arc is increased in size and density, probably metastasic or Paget.
Can you differentiate metastases from Paget?
I agree with MK’s findings. Both Paget and osteoblastic mets can present with increased bone size, however, Paget also demonstrates trabecular coarsening and cortical thickening with an intact medullary space. I think the rib in question is mostly sclerotic and I do not see an intact medullary space. Therefore, I would think osteoblastic mets. Comparison with previous radiographs or CT would be helpful to look for other sclerotic lesions.
In paget disease there is an enlargement of the cortical and increased in size of the bone, with loss of diferentiation between cortical and-medullary, so I think it is a Monostotic costal Paget.
Now the patient can relax!
1. There are fractures in left 8 ,9 ribs and a nodular lesion at the right 8 rib likely extrapulmonary ( fracture? With associated hematoma)
2. the right 6 costal arc is Expanded and increased in density, metastasic/pagets/fibrous dysplasia
In case # 2 you are telling the patient that either she/he has widespread malignant disease or a benign lesion. Can you narrow down the diagnosis?
Most likely benign fibrous dysplasia or pagets
1. Sclerotic nodule right 8th rib
2. Hyperdense rt 6th rib – Paget
first one show fractures in the left lower ribs and 2nd one show icreased bone density and widening of the right 5th rib as a whole suggestive if pagets
1st case male modularlesion in left rib 8,9
Likely posttraumatic calus
2nd case female right 6 rib enlarged sclerotic likely Paget d.
…..gentilissimo PROF., abbiamo due casi, uno con osteoporosi e frattura con callo osseo poco calcifico….l’altro , all’opposto,con diffusa osteosclerosi e lieve aumento di volume dell’osso…..alla base non ci sono malattie metastatiche, ma solamente disturbi del metabolismo osseo, in difetto ed eccesso…..entrambe possono dare dolore….penso così’ di interpretare il tuo insegnamento…..grazie sempre…..con stima da Bari…..