Caceres’ Corner Case 80 (Update: Solution)


Dear Friends,

This week I am showing you a case provided by my good friend Dr. Jordi Andreu. The radiographs below belong to a 39-year-old woman with increased shortness of breath for the last three months. Leave your thoughts and diagnosis in the comments section and come back for the answer on Friday.


1. Bullous emphysema
2. Tension pneumothorax
3. Adenomatoid malformation
4. None of the above

39-year-old woman, PA chest

39-year-old woman, PA chest

39-year-old woman, lateral chest

39-year-old woman, lateral chest

Click here for the answer to case #80

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    Nov 2013
    DISCUSSION 29 Comments

    29 Responses to : Caceres’ Corner Case 80 (Update: Solution)

    1. sameh khodair says:

      Nice to see you Dr. Jordi Andreu
      I see a large emphysematous bulla crossing the mid line superiorly with another small one in the lower left hemithorax, associated pneumothorax with underlying segmental collapse as well as shifting the mediastinum to the contralateral side ( tension pneumothorax )

      • Jose Caceres says:

        Don’t you think that a tension pneumothorax would collapse the bullae?

        • sameh khodair says:

          Its wall may be adherent the lateral chest wall

          • Jose Caceres says:

            You don’t really believe that, do you?

            • sameh khodair says:

              really I cant believe…:)
              but in the same time I had no previous chest imaging for that patient, I dont know if he submitted before for surgical interference as pleurocentesis, However, I see multiple emphysematous bullae of variable sizes with contralateral mediastinal shift, but i am not sure about pneumothorax, but still expect it in the subsequent CT chest of this patient

    2. IMRAN says:


    3. genchi bari italia says:

      Carissimo professore. Non può essere una bolla enfisematosa, perchè l’enfisema polmonare è bilaterale ed in questo caso il polmone dx è sano.Certo vi è un pn-torace( e pn-mediastino)ipertensivo per lo shift a dx dell ‘ombra cardio-mediastica, l’abbassamento della cupola diaframmatica sx e l’allargamento degli spazi intercostLI, MA TUTTO QUESTO è DETERMINATO DALLE CISTI(NON BOLLE, A CAUSA di una parete spessa) di cui almeno una in basso presenta un livello idroaereo, segno di infezione sovrapposta ) per cui penso ad una MACC tipo 1 di Stolker) , complicata da infezione e rottura di una cisti.La MACC è tipica dell’epoca fetale neonatale, ma talvolta, perchè asintomatica, può presentarsi in età adulta a causa di una complicanza.Con la stima di sempre.

      • genchi bari italia says:

        …ad una revisione critica,lo shift cardiomediastinico verso dx, potrebbe essere dovuto ad un enfisema ” lobare congenito”, che nel corso degli anni, iperinsufflandosi, con un meccanismo a valvola ha condotto ad atelettasia del lobo polmonare omolaterale e spostamento del mediastino .La patogenesi dell’enfisema lobare congenito riconosce cause che sono del tutte “differenti” da quello acquisito:ecco perchè, il dosaggio dall’a 1 tripsina può essere nella norma.

    4. Gyan says:

      Multiple Left emphysematous bullae shift of mediastinum to right. One of the bullae is infected with air fluid level.

    5. nicky says:

      Bullous emphysema

    6. Yp says:

      Bullous emphysema-tension pneumothorax

    7. gus says:

      Congenital pulmonary airway malformation type I

    8. Ivan Kirunda says:

      Adenomatoid malformation

    9. Giovanni Battaglia says:

      3 Adenomatoid Malformation

    10. gus says:

      an other hypothesis is, Giant Bullous Emphysema (Vanishing Lung Syndrome)but these is bilateral,usually asymmetric lung involvement and often seen in young men.(fit in with age)
      maybe there is a small bullae on the right lung that we can’t see.
      A CT is necessary.

    11. shaimaa says:

      Large emphysematous bulla with contralateral mediastinal shift

    12. Marcy says:

      There are multiple wall thin cystic lesions, some of then have air-fluid levels. It is causing mediastinal shift toward the right side. It call my attention, that the right hemithorax is almost normal.
      It has to be either a unilateral pathology as Adenomatoid marformation or a pulmonary sequestration, which are rare at this age, usually they are diagnosed in childhood. OR ,I would say that maybe this patient had undergone to right lung transplant, and what we see is sequela of a bilateral patology as cystic fibrosis, alpha 1 AT deficiency, etc

    13. Ali Hamed says:

      Bolous emphysema

    14. Maciej Mazgaj says:

      Another Vote for Bullous Emphysema, vanishing lung syndrome.
      Young patient, proggression in symptoms. It may be unilateral. Mediastinum shifted.
      Am I correst seeing on lateral chest Xray that bullae are mostly in upper and anterior location of left hemithorax? (upper lobe – feature of vanishing lung)

    15. Kotsidis B.N. says:

      We have 1) increased shortness of breath for the last three months. NOT A TENSION PNEUMOTORAX (rapidly instaured )
      2) increased volume Left lung + costal spaces (non an acute process)+abbasament left hemidiaphragm
      3) not so thin walled (less than 1mm air filled spaces).
      4) at the left paracardial-anterior space over the left hemidiaphram . INFECTED CYST OR INFECTED AIR CONTANING EXTRALOBAR SEQUESTRATION ?
      5) conservation of the principal bronchs (smaller angle?
      =rotation ? =pression oh trachea? ) and contralateral mediastinal shift. Shortness of breath caused not by vessels sofference but by expansive left lung process. Right lung has no signs of important sofference.

    16. Joanna M. says:

      Einblutung in Emphysembulla links infrahilär und basal mit Spiengelbildung. Verlagerung der Trachea und des Herzens nach re..
      Pneumothorax bei rupturierter Bulla.

    17. Maia says:

      air lung cysts and adhesive pleursy?