Dear Friends,
Muppet strives to give satisfaction (like Jeeves) and presents you with an easy case:
Fifty-one-year-old male smoker with moderate cough, no fever.
Diagnosis:
1. Metastases
2. Carcinoma of the lung
3. Allergic aspergillosis
4. None of the above
51-year-old male smoker, PA chest
51-year-old male smoker, lateral chest
51-year-old male smoker, coronal CT
51-year-old male smoker, axial CT
Click here for the answer to case #22
PA and lateral chest show an opacity in the left mid-lung field (arrows). Its shape in the lateral view suggests mucous impaction, confirmed with enhanced axial CT (red arrows). Axial CT also shows an endobronchial lesion (arrow), as well as two small lung nodules (arrows). Coronal CT shows an enhancing nodule inside the gallbladder (arrow).
The combination of an endobronchial lesion, pulmonary nodules and a gallbladder mass suggests widespread metastases, with a high probability of melanoma as the primary lesion (it has been described and Muppet has seen several cases). Bronchoscopy confirms the melanotic lesion in the bronchus. Final diagnosis: widespread metastases from melanoma.
Congratulations to all who made the diagnosis, especially to Albert, who contributed with an excellent discussion.
Teaching point: don’t forget the basic principles (satisfaction of search/sex). Once the abnormality is identified, keep looking. This is an easy case if you gather together all the information and don’t choose the easy way out
Allergic Aspergillosis
none of above
Allergic Aspergillosis
Se la mia diagnosi è corretta, il caso presentato dall’illustre collega è veramente bello! si tratta di infarcimento mucoide endo-bronchiale di bronchi dilatati come nell’aspergillosi allergica: infatti l’ipodensità parailare sx è tortuosa e si accompagna ad un vaso satellite; non è allora una troboembolia polmonare, mancandone peraltro gli altri segni TC di una trombo-embolia. La risposta è pertanto la 3. nb non vedo la milza ed il colon sx è alto ( trappola di Muppet?).
Sorry, it is obviously a trappola di Muppet, but not related to the colon
Allergic Aspergillosis
Endobronchial adenoma with bronchocele.
allergic bronchopulmonary aspergillosis, Because aspergillus spores are ubiquitous in soil and are commonly found in the sputum of healthy individuals, Aspergillosis causes airway inflammation which can ultimately be complicated by sacs of the airways (bronchiectasis). The disease may cause airway constriction (bronchospasm). we can see in X-ray and CT above.
Please if it wrong correct me sir. Thank You
Central bronchiectasies with dense mucoid impactions (sometimes can even calcify).
Findings clasically related to ABPA (allergic bronchopulmonary aspergillosis).
Carcinoma lung
allergic bronchopulmonary aspergillosis.Aspergillus spores are commonly found in the sputum of healthy individuals.Aspergillosis causes airway inflammation which can ultimately be complicated by sacs of the airways (bronchiectasis). The disease may cause airway constriction (bronchospasm).
Thank you
ABPA
I have to correct my initial diagnostic: you can see two pulmonary nodules and multiple hepatic solid nodules. Also exophitic mass in the gallbladder.
Maybe metastasic hepatopulmonary disease with endobronchial mets?
The mass in the gallbladder could also be a metastasis.
If my hypothesis are true, the endobronchial and gallbladder mets are unusual and one possible primary tumor is melanoma.
Sorry for the first failed attemp, too fast.
I agree with Albert, it could be melanoma metastases
Apspergillosis
The gloved finger sign of mucous impaction
I agree with you
Central neoplasm of lingula with hepatic hypervascular metastasis in segment V (that should sugest the possibility of carcinoid). The left Nelson bronchia is also filled (carcinoid can be multicentric). There also seems to be a metastasis on the gallbladder (coronal section is oblique to catch all lesions)- lung and melanoma have the most freq mts here. No apparent ADP in mediastinum.
ABPA
allergic bronchopulmonary aspergillosis (ABPA)
allergic bronchopulmonary aspergillosis
Comment to all who answered ABPA. How often the impaction is an isolated finding?
lung carcinoma
The hyperdense material in the gallbladder is most likely sludge, and the liver lesion is hyperdense in a portalvenous phase – therefore it is most likely benign (hemangioma in a discrete fatty liver?).
I could be terribly wrong, though 😉 – looking forward to the solution!
I am pretty sure it is a case of Allergic Bronchopulmonary Aspergillosis. In my hospital I´ve seen similar cases… Am I correct?
Sorry, no. See the answer
Se il ” suggerimento” dell’illustre collega è stato ben interpretato, allora per spiegare un solo impatto endobronchiale mucoide dovremmo pensare ad un a atresia bronchiale, con broncocele impattato.ma la milza dov’è ? c’è polisplenia? Un altro piccolo aiuto illustre collega!!!!
Allergic Aspergillosis