Caceres’ Corner Case 194 (Update: Solution!)

Dear Friends,

Presenting today chest radiographs of a 9-year-old girl with a persistent cough for the last two weeks, vomiting and fever. What do you see?

Check the images below and leave your thoughts in the comments section. More images will be shown on Wednesday, followed by the answer on Friday.

Dear friends, showing a chest radiograph taken seven days later. What do you see?

Click here for the answer


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    Nov 2018
    DISCUSSION 31 Comments

    31 Responses to : Caceres’ Corner Case 194 (Update: Solution!)

    1. Pratiba says:

      There appears to be a cut off sign of the right main bronchus with hyper expansion of the right lung. Possible that there is a foreign body in the right main bronchus.

      • Jose Caceres says:

        To be honest with you, I don’t see hyperlucency of the right lung (look at the vessels).
        Try again 🙂

    2. Jordi says:

      Right paratracheal lymphadenomegaly and blunting of the right costodiaphragmatic recess (suggesting small amount of pleural fluid).
      Tuberculosis is my best guess in this clinical scenario with that radiographic appearance. It could also be sarcoidosis but less likely.

    3. tr says:

      wedge-shaped opacity seen on the lateral view over the anterior costophrenic recess, could not find a corresponding findings on the AP view.

    4. Daniel Furlanetto says:

      I would say there are thickening of the posterior junction line and a small left pleural effusion.

      • Jose Caceres says:

        What you call the posterior junction line is probably the esophagus. No clear signs of pleural effusion.
        Tip: look at the mediastinum

    5. Knkush says:

      Small hyperlucent finding on the left , probably lower bronchus ( retroscardial).tiny foreign body.

    6. S says:

      I’m not sure I can clearly see the aortic knuckle on the PA, even though the mediastinum on the left seems prominent – could be due to rotation to the left.

      On the right there seems to be a round opacity just caudal to the right paratracheal stripe – it might be a slightly enlarged azygos vein, but it might be that the vein is denser and either behind or in front of this slightly more lucent round structure.

      On the lateral I cannot clearly visualize the IVC shadow near the posterior-inferior heart border.
      Could there be some problem with the IVC and subsequent azygos enlargement?

    7. Magdalena says:

      Good morning,

      Occupation of retrotachel space by nodular opacities. Adenopathy? mediastinitis? oesophageal disease? a vascular malformation is less likely, as the patient has acute symtoms.

    8. Miniaturedr says:

      On the PA chest film there is a well shaped right paratracheal mass.
      The differential diagnosis can be aortic arch anomaly (right arch, aberrant right subclavian artery), adenopathy or tumor.

    9. Mk says:

      Where is the aortic knob?on the right side?

    10. MP says:

      A right aortic knob is visible on the PA view. Left aortic knob is not seen. Do CT to look for aberrant left subclavian artery with possible compression of esophagus.

    11. KS says:

      Forigen body in trachea

    12. Márcio Ramos says:

      There’s a enlarged azygos vein in the PA view, and i can’t see a triangular density behind heart in the lateral view, representing vena cava. I think that azygos continuation of inferior vena cava is a possibility.

    13. kannan kanakaraj says:

      1) there is a tubular foreign body with central lumen-? toy in line with tracheal bifurcation and into rt main bronchus producing partial obstruction with obstructive emphysematous changes in rt lower zone, with mild widenind of lower intercostal spaces.
      2) ?suggestion of rt aortic arch or aygos continuation in case of ivc interuption
      3) medial half of left dome not seen clearlyseen with gastric fundus fluid level close to it-? hiatus hernia
      4) ivc shadow not seen clearly in lateral view
      i think i will stop here my imagination running riots

      • Jose Caceres says:

        I think part of your imagination is running wild. On the other hand, part of it is thinking straight 🙂

    14. A. Jaray says:

      Rt hilum uplifted. Follow the old man’s advice!

    15. Gaborini says:

      is there a small air-fluid level on the pa film just above the carina? I do not see it on the lateral view, though.

    16. MK says:

      Gastric bubble on the right side!!
      Abdominal situs inversus with an enlarged azygos vein secondary to interruption of the IVC?

    17. S says:

      Azygos continuation of the IVC and abdominal situs ambiguus (right sided gastric bubble and possibly midline position of the liver) would suggest polysplenia syndrome due to partial absence of right-sided structures (such as the IVC) and predominance of left-sided structures.

      In that case the right lung might have only two lobes, and both sides of the bronchial tree might have left-sided morphology.
      I’m not sure if this is present in this case – the right bronchus seems normal to me.

      • Jose Caceres says:

        You are correct in your diagnosis. Cannot tell about the bronchial distribution because a CT was not done

    18. kannan kanakaraj says:

      latest x -ray chest shows
      azygos continuation with ivc interuption
      retro cardiac density -mucus plug in bronchi or sequestration
      eleven pairs of ribs
      stomach on rt side
      liver on left side

    19. mathi ghtm says:

      altreation in azygoesohageal line and fundal gastric shadow in right