Dr. Pepe’s Diploma Casebook: Case 47 – SOLVED!


Dear Friends,

Today I’m showing a vintage case, seen thirty years ago when I was a promising young staffer. The images below belong to a 57-year-old missionary living in Africa and undergoing yearly controls at our institution for unilateral hyperlucent lung.

Leave me your thoughts and diagnosis in the comments section and come back on Friday for the solution.


1. Swyer-James/Macleod syndrome
2. Bronchial tumour
3. Pulmonary artery stenosis
4. None of the above

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    26 Responses to : Dr. Pepe’s Diploma Casebook: Case 47 – SOLVED!

    1. genchi bari italia says:

      In inspirazione vi è lievissimo shift cardiomediastinico a sx, mentre in espirazione vi è air-trapping del polmone sx; la “vecchia” broncografia dimostra una ipoplasia del bronco principale di sx.Quindi escludiamo la S.diSJ-mc Leod che è una conseguenza di bronchioliti , con ipoplasia vascolare; escludiamo la stenosi arteria polmonare, perché non dimostrata; escludiamo il CR bronchiale in relazione alla regolarità della stenosi bronchiale:rimane una ipoplasia polmonare bronchiale, con air-trapping da pori di Khon per le collaterali di areazione.

      • genchi bari italia says:

        Wanishing-lung o Sindrome di Giano, dovuta ad ipoplasia arteria polmonare con conseguente rarefazione del disegno polmonare ed “air-trapping” attraverso i pori di Khon.

    2. Mila says:

      There is hyperlucent left lung with shifting of the mediastinum to the left side during inspiration. Huperlucent lung remains in the image during expiration. Pulmonary arteriogram shows no appearance of the LUL pulmonary artery and descending pulmonary artery is seen partially. Hyperlucent lung is due to diminished vascular blood flow. Because it is long term disease- patient ungergoes yearly controls- I vote for Swyer-James syndrome.

    3. sameh khodair says:

      Hi, Prof. I hope that you are fine
      I see in this case that there is hypoinflation of the left lung in the inspiratoty film with markedly attenuated its bronchovascular markings. In CT angio study, there is marked hypo-perfusion of the left lung in a symmetrical manner with relatively small left pulmonary branch in comparison to the right branch , this is consistent with Mcleod syndrome

    4. sameh khodair says:

      sorry , not a CT angio, It is a conventional pulmonary angiography

    5. Ziad Al-aghbari says:

      Hello prof.
      I will go here with Swyer-James /Macloed syndrom.
      There is hypoinflation in the left lung with compensatory hyperinflation in the right lung as seen in the inspiratory film and air trapping in the left lung as seen in the expiratory film.which Is believed to be a sequale to old bronchiolitis.
      And there is left pulmonary artery hypoplasia as shown in the conventional pulmonary angiography.which also described in Macleod syndrom.

    6. gus says:

      There is hyperlucent left lung with shifting of the mediastinum to the left side during inspiration.
      we have lost of volume of the left lung with expiration too.(elevetion of the left hemidiaphragm.)
      there is not Swyer-James syndrome.
      on the frontal view we have enlarged of the pulmonary’s hilum and donuds sing on the lateral view.
      on the pulmonary arteriogram, main branches of pulmonary arteries looks good but we can t see after main left pulmonary arterie but only a few branches of the LUL.(or hypoplastic or obstructive) the missionary of Africa is a good information (i am sure…) but i don t now yet how to make the conection.
      9 rib fracture on the right.

    7. gus says:

      i am change my mind is Swyer–James–MacLeod syndrome

    8. MacMaz says:

      Both radiographs show hyperlucent left lung, with reduction of bronchovascular pattern. There is normal diagphram function allthough left dome is elevated, it may result from volume loss of the left lung. Mediatinum is shifte to the right during inspiration, indicating that the lung is not only of a reduced volume, but also is not ventilated equally with the opposed side. What is more, we see the reduced branching of the left pulmonary artery, but the pulm. trunk and main left pulm. artery are normal in size – it neglect the congenital cause of the problem visualized.
      Summarizing: lef tung of a reduced volume, limied ventilation and blood supply, resulting from not congenital reasons.
      All my votes for Swyer-James Syndrome.

      BTW. Do I see contast agent in patient’s aesophagus on the lateral CXR?

      • Dr. Pepe says:

        No, there is no contrast in the esophagus.
        I believe your interpretation of the findings is correct.
        You overlooked the cause.

    9. Dr. Pepe says:

      I imagine many of you are waiting for a hint. Will give you two:
      1. Correct diagnosis has not been mentioned.
      2. Look at the films

    10. Farzaneh says:

      4.None of the above
      It’s a Case of Unilateral bullous emphysema of lung.

    11. There is mild left side cardiac and mediastinal displacement, smaller hemithorax; absent pulmonary artery shadow; ipsilateral hemidiaphragm elevation; ipsilateral absent or grossly diminished pulmonary vascular markings; and contralateral lung hyperinflation and herniation beyond the midline and no air trapping on the expiratory chest radiograph. SO I WOULD SUGGEST IT TO BE A UNILALATERAL PULMONARY ARTERY AGENESIS
      The principal differential diagnosis is Swyer-James or McLeod’s syndrome in which the affected hemithorax may or may not be small, the expiratory radiograph shows air trapping,

      • Juned A Ansari says:

        nice case professor….really tough one !
        although you mentioned that there was air trapping in expiratory view..but i was unable to appreciate.
        Anyway thanks again for the nice teaching points.
        looking forward for your next case.

    12. gus says:

      There is not air trapping.
      simple the right lung is working and the left no.
      is not Swyer–James–MacLeod syndrome

      -In unilateral bronchial obstruction the mediastinum shifts towards the abnormal lung on inspiration and towards the normal lung on expiration.case 58

      -On the Left Pulmonary Artery Hypoplasia the most frequent findings on the chest x-ray include decrease in size of the affected hemithorax and compensatory hyperinflation of the contralateral hemithorax, elevation of ipsilateral diaphragm and ipsilateral shift of mediastinum.

      the problem is that we can see the main branch of Left Pulmonary Artery that is no atresia.(it was great..)

      is not bronchial tumor.

      i think is a kind of hypoplasia or a chronic stenosis of the artery

    13. RADIOIMAGER says:

      answer is 4

    14. genchi bari italia says:

      ..in AP l’ilo di sx non sembra corrispodere all’arteria polmonare che è ipoplasica( vedi angio-pneumo); in LL si conferma una opacità ilare di ndd.Potrebbe trattarsi di un broncocele, conseguente al difetto vascolare, mentre l’ipertrasparenza “bloccata” trattarsi di un difetto di svuotamento respiratorio conseguenziale.

    15. gus says:

      i will say somethink else because is the last day.
      the aortic arch it looks like be in both sides of the trachea.
      a double aortic arch with compression of the airway?

      is very difficult case profesor and the films it doesn’t help
      sorry 🙂

      • Dr. Pepe says:

        Actually, you saw the lesion in the PA view. Looking at the lateral view, the tumor is very obvious, projecting over the tracheal lumen.
        The films do help: the diagnosis was made in the plain film and later confirmed with CT and bronchoscopy after the tumor has been overlooked for a few years.
        Unlike you, I believe the case is easy if you look at the lateral view, as I did thirty years ago.

        • gus says:

          sorry for my bad english.
          i mean the quality of the films….
          professor i love the films too 🙂

          i think my quality is not good because the mass was there and i didn’t saw it.
          i will try harder next time.

          ps: i am sure thirty years ago you was the same great mind as you are now.

          • Dr. Pepe says:

            Your English is OK. The important thing is to discover the lesion and to make an educated guess.
            I do not have a great mind: just apply basic knowledge.

    16. MazMac says:

      It is difficult case.
      My previous post where I voted for Swyer syndrome was not published.
      Lateral and PA film both show hyperlucency mainly in the area of left upper lobe, mainly it’s ventral parts. No signs of chest surgery. How about some limited no-tension pneumothorax? Lobe affected by bullous changes? I give up:)

    17. sameh khodair says:

      But excuse me , it is a case of air trapping by a bronchial and left bronchus mass, so what is the mechanism of vascular attenuation ??