Caceres’ Corner Case 166 (Update: Solution)

Dear Friends,

This weeks’ radiographs belong to a 31-year-old male with vague chest complaints. What do you see?

Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.

Click here for the answer

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    Sep 2017
    DISCUSSION 20 Comments

    20 Responses to : Caceres’ Corner Case 166 (Update: Solution)

    1. Mk says:

      Good morning! The x-ray is rotated, so the right paratracheal line is thickened.

      There is an increased density proyected over the left cardiac region, that in the lateral view has vascular appearance. The lower right hemithorax has less vasculature than the left one.

    2. Olena says:

      Patient’s position is rotated due to the skoliosis, that is why the projection of the mediastium, trachea seems abnormal

      There is hyperlucent RLL with further poor lung vasculature, making decrease attenuation of the upper part of diaphragm – bulla of the RLL

      The changes first suggesting bullous disease

      • Olena says:

        But the absence of thin lines caused be thin walls of bulla, is against this. As the absence of pneumothorax as common and often complication too.

        Maybe there is a vascular abnormality – vascular hypoplasia/ or lung hypoplasia.

        • Olena says:

          Righ middle lobe aplasia

          • Jose Caceres says:

            What would you do to prove this diagnosis?

            • Olena says:

              I looked over radiographs and my previous comments and would like to re-formulate my thoughts:

              1. I think unilateral pulmonary hypoplasia can be excluded – usually it is associated with scimitar syndrome, other vascular abnormalities; affected lung is small, mediastinum shifted into the ipsilateral hemithorax.

              2.Next two abnormalities should be differentiated – agenesia and aplasia, the last one has a rudimentary bronchus.

              These abnormalities can affect both lung and one lobe isolated.

              On this radiographs it is more likely isolated lobe agenesia/aplasia because there is compensatory hyperexpansion of the RLL and as a result distortion of vessels.
              Though there is compensatory hyperexpansion but still the lung volume is reduced (mediastinum slighly shifted to the right and elavated diaphragm)

              There are one more two abnormalities for differentiation: bronchial atresia (common triad – central mucocele, hyperlucency and hypoperfusion of affected segment) and congenital lobar overinflation (neonatal manifestation)

              The best way to prove this diagnosis is to do bronchoscopy

    3. Tamara says:

      9th rib from right side is abnormal

    4. kuba says:

      cardiac bronchus

    5. Borsuk says:

      I’m agree with Olena – there is less vasculature of lower pole of right lung. Conclusion – Westemark sign in PE.

    6. Mark says:

      The right heart border is poorly defined on the PA. The vessels extending from right hilum seem crowded and displaced medially.
      On the lateral I see a faint opacity overlying the heart. To me this seems wedge-shaped, and I also see vascular structures within the retrocardiac clear space.
      Although my knowledge is limited, I think this is a right middle lobe collapse with compensatory hyperinflation of inferior right lobe.
      I would do CT to confirm and rule out retrocardiac or endobronchial mass.
      Thank you for letting me participate.

    7. TR says:

      hypelucency of the right lower lung zone with diminished vascularity, no increase or decrease in volume, no enlargement of the right pulmonary artery, my suggestion is Swyer-James syndrome/obliterative bronchiolitis.

    8. María P. says:

      There is hyperlucency of the right lower lung, with segmentary hypovascularization. Was this Xray taken in ER? Pulmonary embolism?

    9. genchi bari italia says:

      ipoplasia arteria polmonare dx, con ipolasia POLMONARE, MI SEMBRA UNA BUONA DIAGNOSI…..ASPETTANDO L’ANGIO-TC….DA bari un caro saluto….

    10. sabry says:

      scoliosis upper thoracic spine .
      hyper ventelation rt lower lobe lung