Dr. Pepe’s Diploma Casebook: Case 109 – The Wisdom of Dr. Pepe (Chapter 2) – SOLVED!

Dear Friends,

To continue with the second chapter of The wisdom of Dr. Pepe, I am​ showing radiographs of a 75-year-old man with cough and haemoptysis.
What do you see?

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

Click here for the answer

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    12 Responses to : Dr. Pepe’s Diploma Casebook: Case 109 – The Wisdom of Dr. Pepe (Chapter 2) – SOLVED!

    1. MK says:

      Good morning!

      Emphysematous thorax with bilateral apical tracts, more evidente in the right region where I can see an apical cap and a nodular lesion in the paratracheal margin and bronchiectatis (perhaps fibrotic changes because of a chronic pathology or a new lesion growing over them).

      In the lateral view the hila are enlarged with high density, and there is an alveolar opacity in the LLL (like in the PA view).

      So haemoptysis because of chronic changes or a neoplasm.

    2. Y.E. says:


      – Emphysematous thorax.
      – Bilateral apical fibroreticular opacities + bronchiectasis, with upward retraction of the hila.
      – Tracheal displacement (apical retraction vs goiter)
      – Posterior LLL nodular opacities.

    3. AYS says:

      -Bilateral apical fibrosis and cavitation
      -Patchy pleural thickening /calcifications
      -Tracheal narrowing
      -Peripheral tree in bud pattern
      mostly Tuberculosis

    4. Ren says:

      Emphysematous thorax
      bilateral apical pleural caps right more than left. Fibrotic changes in the right apical region in the form of tracheal deviation and broncciectasis.
      a nodular lesion in the right apical region.
      an opacity in left mid zone could represent a lung nodule however could be due to the indentation by the costochondral junctions.
      In the lateral view nodular opacity is seen in the hila.may represent lymph nodes.
      So haemoptysis because of bronchiectatic changes or a neoplasm.

    5. genchi bari italia says:

      …carissimo Prof……la trachea in AP e LL è improntata e ristretta , da una opacità di massa….

    6. Sofia Nikolakopoulou says:

      Where is the right atrium of the heart?

    7. MP says:

      Extensive emphysematous and fibrotic changes. Hilar lymphadenopathy. There is a nodule in the periphery of the left lung with peripheral clearing. This may be an aspergilloma.

    8. Stevan Vasiljević says:

      First to note the underlying chronic pathology:
      1. Emphysematous changes (hyperinflated lungs, increased retrosternal clear space…)
      2. Old TBC (fibrotic changes in the apical zones, especially on the right, where some small cavitations are present, upward traction of hila, pleural caps…).

      There is also an ill defined nodule in the middle left zone, which on LL seems to be placed posteriorly, possibly also scaring from TBC.

      However, I see other abnormalities:
      – Although both hila are elevated, right hilum is higher then the left one, indicating volume loss.
      – There also appears to be hillar mass on the right.
      – Trachea is narrow in the middle part and deviates to the right, as if being pushed by the paratracheal mass on the left, and not because of aortic knob, which is below the deviation.
      – On the lateral view trachea is not vertical, but is displaced posteriorly in it’s lower part by a mass at the level of right pulmonary artery.
      – There is also soft tissue structure anterior to the trachea.

      Everything said could be due to reactivated TBC with lymphadenopathy, but neoplasm can’t be excluded, so I think this patient warrants a CT exam.

    9. Daniel do Brasil says:

      Emphysema, probable tb sequelae (pleural caps, bronchiectasis, scarring predominant in the upper lobes, which determine hilar elevatio and right tracheal dislocation).
      Middle lobe atelectasis also looking residual.
      Narrowing of trachea – could it be the cause of synptoms? (looks saber sheath like in the profile).
      Bilateral nodular opacities more numerous on the LLL – tb? Mets? Angioinvasive aspergilosis?
      Nice case, dr pepe! Looking forward to your insight!

    10. Dr Pepe says:

      Sorry I could not make any comment this week. Case was presented to emphasize the importance of the lateral view, in which the left hilum is abnormal and irregular. As many of you mentioned, CT should be done.
      Thanks to you all for participating