Caceres’ Corner Case 95 (Update: Solution)


Dear Friends,

Today we are wearing typical Basque txapelas; a gift from my good friend Dr. Estibalitz Montejo from Bilbao.

Below are two radiographs of a 45-year-old male with acute chest pain. What do you see? What would be your diagnosis?

Leave us yout thoughts in the comments section and come back on Friday for the answer.

PA chest

lateral chest

Click here for the answer to case #95

Be Sociable, Share!
    Jun 2014
    DISCUSSION 30 Comments

    30 Responses to : Caceres’ Corner Case 95 (Update: Solution)

    1. Miryam Antigona Ospina Quintero says:

      three are two finds, right paratracheal opacity and retrocardiac opacity as hiatal hernia

    2. MaryVi says:

      In the first x-ray I see a retrocardiac opacity that is confirmed in the lateral view and surgical clips in the LUQ.
      In the second one, there are more surgical clips, this time they are project in the posterior mediastinum, in the aortic or esophageal wall??

      • Jose Caceres says:

        There are also clips in the upper abdomen. Patient was operated on for carcinoma of the lower esoghagus in 2005. No problems since then.

    3. Val says:

      Sorry, German: Vd.a. Neurinoma im unteren BWS-Bereich bei angedeutet weitem Neuroforamen in seitlicher Projektion oberhalb des Zwerchfells.

    4. Maria says:

      There is also absence of vessels at the right apex which can be
      1.a secondary esophageal diverticulum
      2.rupture of a pulmonary bulla
      3.any other idea?

      • Jose Caceres says:

        Good observation. I would expect a ruptured bulla to have an air-fluid level at the botton.

    5. gaborini says:

      There’s an azygos fissure, with a position more caudad than normal. There are no vascular markings cranial to the azygos fissure. To me these findings suggest a pneumothorax confined in an azygos lobe.

    6. asdf says:

      Left apex seems abnormal -is it only my imagination?

      Dear Professor why are You using jpg intstead of DICOM?

      • Jose Caceres says:

        Sorry, you are imagining things 😉
        I am using jpg because most of the cases are from my private collection and all of them are on jpg format.

    7. mod says:

      pulled up stomach

      • Jose Caceres says:

        Yes, the patient had been operated on. But it is not the intended diagnosis.

    8. Jose Caceres says:

      I believe you all are failing to see the obvious.
      Take a step back and look at the PA chest.

    9. Anna says:

      Old costal fractures on the both sides – most probably due to the operation.
      Giant bulla in RUL (it would be good to compare to the previous CXR). But bulla is not painful, and here is no pneumothorax. Why patient has chest pain? Is the answer on this CXR?

    10. Prasanna Kulkarni says:

      Left apical pleural thickening is seen. Possibility of a left pancoast tumour needs to be considered.

      In a patient operated for esophageal cancer, the upper thoracic levoscoliosis is worrisome for me. Possibility of vertebral metastases needs to be considered.

      The hyperlucency in the right apex, devoid of vascularity is most likely due to a bulla. There is no tracheal deviation to suggest localized pneumothorax.

    11. Luis Cueto says:

      We can see a triangular opacity both rigth paratracheal and left cardiophrenic angle, Can be two focus of pulmonary tromboembolism?.
      Best regards to Prof Cáceres.

    12. gus says:

      oesophageal-pleural fistula ?

    13. genchi bari italia says:

      …gentilissimo professore….in AP immagine rx-trasparente in sede apicale dx, da probabile cisti aerea infetta…..alla base toracica posteriore sx, “opacità” retrocardiaca a sx, con sospetto di area libera sovrastante….clinica di dolore acuto toracico, senza febbre e-o dispnea, in soggetto con pregressa operazione chirurgica dell’esofago distale….penso ad una complicanza “tardiva” di tale intervento a carico del segmento intestinale utilizzato per anastomizzare l’esofago residuo allo stomaco….complicanza di natura “ischemica” il che potrebbe spiegare il dolore “acuto” a febbrile…ischemia con perforazione del segmento intestinale….

    14. roro says:

      i suggest esophageal rupture causing pneumomediastinum

      • roro says:

        the heart is outlined by a thin lucent lint and there is a suspicious lucency seen overlying the left cardiac shadow could represent naclerio v sign.

        also on the lateral view there are lucent lines outlining the mediastnal structures

        these findings likely represents pneumomediastinum and from the surgical clips seen and the history of the patient likely the cause is reputed oesophagus

    15. Jose Caceres says:

      How come that nobody is looking at the pulmonary vessels?

    16. Jose Caceres says:

      Putting it in a different way: what do think (and look for) in a paient with acute chest pain?

    17. genchi bari italia says:

      ….se dobbiamo guardare i vasi polmonari….essi sembrano collegarsi con la opacità basale sx…..allora una MAV?

    18. Laurens says:

      Right apical oligemia suggesting pulmonary embolism?

    19. Bibi says:

      Right Apical Bulla
      Left Pulmnory Artery Embolism /Infartion Lower lobe

    20. edita says:

      Pulmonary Embolism

    21. genchi bari italia says:

      …..grazie mitico!!!!NB il Bari è ai play-off per salire in serie A…Aspettaci BARCA!!!!!