Dr. Pepe’s Diploma Casebook: Case 114 – SOLVED!

Dear Friends,

Today I am presenting radiographs of an 80-year-old man with productive cough and fever. What do you see?

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

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    Oct 2017
    DISCUSSION 12 Comments

    12 Responses to : Dr. Pepe’s Diploma Casebook: Case 114 – SOLVED!

    1. Olena says:

      There is thorax cavity deformation due to IV stage scoliosis. This leads to abnormal visualization of all intrathorasic structures – trachea, mediastinum are shifted to the left.
      Left lung seems to be decreased in volume.
      There is pleural calcification seen on the left and the horizontal line – air-fluid level in the cavity.

      1. necrotizing neumonia
      2. lung abscesse
      3. Pleural empyema
      4. Cavitary lung cancer/squamous cell ca

      Are there any information about thoracoplasty?

      • Dr Pepe says:

        No previous thoracoplasty

        • Olena says:

          Is there any information about sputum analysis, bronchoscopy?
          And how many years this patient has this scoliosis?
          Are there any previous plain films?

          The right lung looks normal, but this mild ground glass opacity on the level of IVth rib – this is summation?

          (Seems this is the case with trick?)

          It could be also the patient after lobeectomy (lll?) or pulmonectomy – is there any information abour previous surgeries?

          • Olena says:

            Those pleural calcification commonly associated with asbestosis exposure

            • Dr Pepe says:

              Too many questions 😉
              No previous surgery
              Scoliosis since youth
              Pleural calcium associated to asbestos is usually bilateral

    2. Mk says:

      Severe scoliosis.
      Loss of volume of the left hemithorax (previous lobectomy?).Diffuse left pleural calcifications and rectification of the left bronchus. Hidroaereal level. If personal history of TBC, we have to think on sobreinfected bronchopleural fistula…

    3. MP says:

      I agree with stated findings of Olena and MK.
      Severe dextroscoliosis, decreased left lung volume, left-sided pleural effusion with pleural calcifications.
      If this is recurring, neoplasm is possible. Bronchopleural fistula may be present if there is a history of TB.

    4. medicus1983 says:

      In addition to the above mentioned statements I would add asbestosis-related disease and keep in mind probably diffuse pleural mesothelioma if there is known inhalational exposure to asbestos fibres.

    5. Genchi bari italia says:

      Fistola bronco pleura per la presenza di livello idro-aereo, nella cavità’ pleurica..

    6. TR says:

      – marked deformity in the chest wall due to the severe thoracocervical rotatory dextroscoliosis.
      – extensive pleural calcification in the left chest (DDX: hx of tuberculous pleural disease, hx of hemothorax/empyema, hx of talc pleurodesis).
      – ill-defined peripheral opacity over the right middle zone (true lung lesion vs. chest wall lesion/breast tissue shadow), and if its a true lung lesion, then it might represent an infection or a neoplasm.


    7. Dr Pepe says:

      At this stage, it is obvious that the most likely diagnosis is broncho-pleural fistula. Congratulations to MK, who was the first to state unequivocally that the patient had a BPF.