Dr. Pepe’s Diploma Casebook: Case 115 – SOLVED!

Dear Friends,

Today I am presenting radiographs of a 60-year-old man with a cough and moderate fever.


1. Viral pneumonia
2. Non-cardiac pulmonary edema
3. Pulmonary hemorrhage
4. None of the above

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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    Nov 2017
    DISCUSSION 10 Comments

    10 Responses to : Dr. Pepe’s Diploma Casebook: Case 115 – SOLVED!

    1. Mauro says:

      Good morning. There are billateral reticulonodular opacities located in the lower two thirds of both lungs. I can also see a small triangular opacity at the region of the right cardiophrenic angle. I think there could also be thickening of the right paratracheal line, with apparent occupation of the anterior clear space. Maybe the answer is number 4: lymphangitic carcinomatosis.

    2. Mk says:


      Superior esophageal dilatation (in lateral view there is anterior tracheal displacement). Bilateral alveolar opacities in inferiors hemithorax, so I think in aspirative pneumonie.
      There is an increased density in the right cardiophrenic angle and obliteration of the retrocardiac space.

      So 4. Any of the above: Aspirative pneumonie because of esophaeal pathology

    3. Coffee says:

      There are reticulonodular and patchy opacity in bilateral mid and lower lung zones, could be due to infection, inflammation or malignancy
      There is proximal esophageal dilatation with air fluid level, suspected esophageal lesion.
      There is soft tissue opacity at right cardiophrenic angle with bulging contour, possibly mass lesion or enlarged nodes.
      There is suspected LA enlargement.

      The answer: No 4. None of above

    4. MP says:

      I see an air fluid level in the esophagus with bilateral pulmonary infiltrates in mid and lower lung zones most likely due to aspiration pneumonia. Irregular opacity in the right cardiophrenic angle – would consider an esophageal diverticulum and achalasia as a cause of the esophageal air fluid level.
      Double density sign of the right heart border on PA and bulging of the posterior aspect of the cardiac silhouette on lateral suggests left atrial enlargement.

      answer: 4 none of the above

    5. Olena says:

      there are peribronchovascular changes, multiple ill-defined nodules in both lung, predominantly in upper lobes and the infiltration in the RUL on the level of IIId intercostal space – IVth rib

      there is hyperlucency in the upper mediastinum and opacity in the posteriobasal origin – most likely corresponding to widened esophagus

      4. none of above, DDX :
      – esophageal tumor (GIST) with suprastenotic esophageal widening and aspiration pneumonia
      – the esophageal diverticulum with further aspiration pneumonia
      – postoperative condition (surgically treated achalasia oesophagogastroplasty?) and aspiration pneumonia

    6. Dr Pepe says:

      Thursaday evening recap: achalasia with chronic aspiration. The key to the diagnosis is recognizing the dilated esophagus with an air-fluid level.
      Gold medal to MK, who was the first to mention the diagnosis