Caceres’ Corner: Case No. 45 (Update: Solution)


Dear Friends,

We are having a December sale (everything must go!) and during this month Muppet will show only cases with air-fluid level. We start with a vintage case (2002) of a 76-year-old male with left lower lobe pneumonia.


1. Infected bulla
2. Congenital cyst
3. Pneumatocele
4. None of the above

76-year-old male, PA chest

76-year-old male, lateral chest

Click here for the answer to Case 45

Be Sociable, Share!
    Dec 2012
    DISCUSSION 17 Comments

    17 Responses to : Caceres’ Corner: Case No. 45 (Update: Solution)

    1. Ricardo Macareno says:

      The most likely diagnosis is an infected bulla. Identify signs of lung hyperinflation (flattened diaphragm, increased retrosternal air ..). It supports the existence of a left lower lobe pneumonia with concomitant emphysematous bulla secondarily infected.

    2. froso says:

      This time thinking simple.

      The air-fluid level is located in the posterior mediastinum.
      Possible diagnosis: a hiatal hernia (also can’t see the gastric fundus below the diaphragm)
      Also there is LLL pneumonia ( posterior- inferior segm of LLL)due to aspitation- (when having a hernia, reflux of gastric contents in supine position causes aspiration pneumonia in this old man).

    3. Genchi Bari Italia says:

      Risposta secca:acalasia esofagea con broncoplmonite da bronco-aspirazione. Salvate MESSI!!!!!

    4. Xose says:

      4. None of the above
      It looks like a hiatal hernia, althoug the lesion is posterior and lateral
      To point out other options, traumatic diaphragmatic hernia?
      intrathoracic gastroplastia?

    5. ardeshir says:

      none of the above
      diffretial diagnosis are:1.aschalazia 2.paraesophagial hiatal hernia

    6. Dr Hesham Alfetiani says:

      Infecteted bulla.due to patient’s lung appearance

    7. RadLex says:

      There is a left posterior mediastinal mass with an air-fluid level and a left lower lobe consolidation. This is most likely a left Bochdalek hernia

    8. Dr Strangelove says:

      There is some LLL atelectasis, so the mayor fissure should be displaced to the position where the lenticular discoid image is. The air-fluid level is wider in the lateral chest Xray than in the PA suggesting also pleural origin.
      Loculated hydropneumothorax.

      • Jose Caceres says:

        Good thinking! Tell me where the loculation is and you will be a hero.

        • Dr Strangelove says:

          Well, I mean that the loculation is IN the mayor fissure (displaced because of the atelectasis).

        • Dr Strangelove says:

          By the way, what is that air anterior to the trachea (lateral view) ? Some kind of contralateral lung herniation ?

          • Jose Caceres says:

            You are a hero! Congratulations!
            I cannot answer your question. This is an old case and I have only a few CT slices of the lower chest.

    9. genchi bari italia says:

      La “sede” del livello idro-aereo, cioè se intra-polmonare o pleurica si basa appunto sulla “differente” morfologia, rispettivamente sferica od allungata , nei diversi radiogrammi(AP-LL-IN DECUBITO lat): tuttavia nel caso in oggetto , la reale grandezza del livello è ,in AP, parzialmente mascherata dall’opacita’ cardiaca.Inoltre è stato suggerito che l’opacità polmonare sia una polmonite( post-ostruttiva?).Un idro-pneumotorace,saccato, allora dovrebbe derivare da fistola broncopolomonare , per necrosi tumorale, in soggetto con precedenti pleuritici.

    10. Dr baqi says:

      Infected bulla most likely