Muppet has chosen to show a case from the Iron Islands. Winter is coming …
An 83 year-old lady with cough and moderate dyspnea.
1. Normal for age
2. One process
3. Two processes
4. Three processes
In the PA view there is an intrapulmonary nodule in the right costophrenic angle. It is intrapulmonary because the lower border is surrounded by air (arrow). In addition, the descending aorta is prominent, whereas the ascending aorta is not. This is a sign which suggests type B aortic dissection in the plain film, which should be confirmed or discarded by CT.
Fig. 1
CT confirms the dissection (A, B arrows), as well as a low-density nodule (15 H.U.) at the right base (A, C arrow). Nodule had not changed at one-year follow-up. Final diagnosis: two processes, benign lung nodule and type B aortic dissection.
Fig. 2
Teaching point: always look at the costophrenic angles in the PA chest. You may find a lesion occasionally (as in this case). Remember that when, in old age, aorta elongates, there is prominence of both the ascending and descending aorta. When only the descending is prominent, discard type B dissection (see case 18).
