Caceres’ Corner Case 167 (Update: Solution)

Dear Friends,

Today I am showing a case seen one month ago. Radiographs belong to a 64-year-old man with intermittent fever for the previous two weeks. 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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    Oct 2017
    DISCUSSION 25 Comments

    25 Responses to : Caceres’ Corner Case 167 (Update: Solution)

    1. Olena says:

      On the level of trachea lumen (trachea is normal) there is hyperlucency which I can not see on the lateral view.

      There are interstitial changes in both lungs with small multiple barely noticeable nodules mostly in lower parts of both lungs – reticulonodular pattern.

      On lateral view there is an ill-defined opacity on the level of left lower bronchus and LLL hypoventilation suggested (the major fissure on the left is shifted down).

      Both hila are enlarged – suggesting bronchopulmonary lymphadenopathy

      1/ lymphangitis carcinomatosis
      2/ occupational disease (silicosis)
      3/ sarcoidosis

      • Olena says:

        Are there previous X-ray?

        • Jose Caceres says:

          There are no previous radiographs

          • Olena says:

            Are there any information about connective tissue disease – rheumatoid arthritis?

            I suppose some variant of the interstitial pneumoniae should be added for differential diagnosis

          • Olena says:

            I wrote that both hila are enlarged.
            Is there an oval mass which is projected on interlobal artery on the right?

            • José Cáceres says:


            • Olena says:

              Are there two nodular opacities on the right on the level of the first rib in subpleural region?

              Is this patient HIV positive?

              I suppose tuberculosis also should be added – it could be tuberculoma on the hila level and miliary dissemination, but distribution is not typical

              The question also is there on lateral view opacity in front of trachea (lymphadenopathy? Mass?)

              What are the clinical data except fever? Sputum analysis? Bronchoscopy?

            • Olena says:

              There is also slightly obsuring lung space on the right on the apex and near mediastinum – visceral pleura thickening, or I “see” too much?

    2. TR says:

      – bilateral symmetrical fine reticulonodular interstitial pattern in the lung bases without remarkable volume change.
      prominence of the right descending pulmonary artery.
      – unusually prominent shadow of the steroncleidomastoid muscles giving the V-shaped lucency over the trachea.

      the findings indicate interstitial lung disease with predilection to the lower zones with no significant volume change, the differential diagnosis is wide, and the presentation suggests acute/subacute disease: acute interstitial pneumonia (viral, mycoplasma..), LIP, inhalation disease, drug reaction, connective tissue disease, and idiopathic disease.


      • Jose Caceres says:

        How do you value the prominence of the right pulmonary artery?

        • tr says:

          I think it is fair to say that there is bilateral hilar prominence, and possibly a pretracheal density, with the interstitial disease I think it is reasonable to consider stage II pulmonary sarcoidosis (a great mimicker), although the interstital pattern is not in favour of it.

    3. Mk says:

      Prominent hilios and reticular bilateral pattern. Right paratracheal line is thickened. In the lateral view there is an increased density anterior to the trachea.
      Sarcoidosis or TBC

    4. Lucretius says:

      Hyperlucent lesion in tracheal level. Zenker diverticulum? We can think in chronic aspiration with an intersticial pattern in lower lobes. There is also hilar prominence bilaterally.

      Lucretius – Brazil

      • Jose Caceres says:

        Glad to have a Brazilian on board! The hyperlucent lesion is a suprasternal notch, which is a normal finding.
        Keep looking 😉

    5. Daniel Furlanetto says:

      Maybe shooting for the stars, but I would build a differential diagnosis over pulmonary cavities + micronodules… in this case TB would be quite all right except for the distribuition. Poliangiitis with granulomatosis (Wegener) would be a good fit, but quite uncommon. Squamous carcinoma metastases and septic emboli would also be in the possibilities.
      If, however, my “quijotean” eyes made the cavities… I’d stick with the previous opinions and go for sarcoidosis.
      Final bet still Wegener.

      • José Cáceres says:

        Your eyes deceived you 😉

        • Daniel Furlanetto says:

          Windmills not giants… So I guess our colleagues have already said it…

          • Jose Caceres says:

            Don Quixote never gave up. Why should you? I still don’t have a clear winner.

            • Daniel Furlanetto says:

              You are right, professor… the dice rolls still. Maybe I am still hitting on the windmills, but with the cavities out of the way, I would go for hypersensitivity pneumonitis. The enlarged lymph nodes are not that commonly associated, but they can be, so that is my new bet.

    6. sabry says:

      interstetial lung disease ,rt lowe r lung opacity

    7. Josias Moura says:

      I’m Brazilian and I’m doing a radiology course and I always look for extra knowledge on the internet. I just found out your blog and I’ve already put it in the favorites.

      I do not speak English so I have to use Google Translate.

      • Dr Pepe says:

        Welcome! You can write your answer in Brazilian if you feel more confortable. I believe I can understand it.