Dear Friends,
Muppet is very happy with your progress and wants to test you with an unusual case.
A 57-year-old male with liver carcinoma. No chest symptoms.
What are the densities in the upper lung and mediastinum?
1. Veins
2. Arteries
3. Lymph nodes
4. Esophagus
Warning: this is a difficult case!
57-year-old male, AP supine chest
57-year-old male, erect lateral chest
PA chest shows a tortuous line in the left side of the mediastinum (arrows), as well as an azygos fissure (arrows) with an enlarged azygos vein (white arrow). The lateral view shows a prominent azygos (arrow) and an ill-defined haziness in the lower middle mediastinum (white arrows).
The findings suggest an enlarged azygos/hemiazygos system accompanied by an azygos lobe. Findings are confirmed by coronal and sagittal CT, which show the enlarged azygos and hemiazygos veins (arrows). Axial CT shows the azygos lobe (arrow).
Muppet was surprised because these findings were not related to liver disease or varices. The patient had a congenital absence of the inferior vena cava with azygos continuation, combined with an azygos lobe. Muppet’s alter ego published this rare combination a long time ago.
Teaching point: if we pay careful attention to the findings and make a good semiologic reading, it is possible to diagnose unusual conditions, as proven by the many correct answers to this case. Congratulations!
