Dr. Pepe’s Diploma Casebook: Case 49 – SOLVED!


Dear Friends,

The first case of 2014 belongs to a 40-year-old male with a mild cough. What would you suspect?

1. Tuberculosis
2. Carcinoma
3. Enlarged left pulmonary artery
4. None of the above

Check out the images below and leave your thoughts and diagnosis in the comments section.



Click here for the answer

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    29 Responses to : Dr. Pepe’s Diploma Casebook: Case 49 – SOLVED!

    1. Gabriela says:

      There is an unilateral left-sided mass in a hillum. In the differential diagnosis sign is characteristic for carcinoma. It’s margine is rather ill-defined which excludes left pulmonary artery enlargement. Upper zones billaterally and right paratracheal region seems to be unaffected which excludes TB.

    2. Dylan says:

      Left side hilar ill-defined irregular mass. DDx includes malignant lesion vs lymphadenopathy.

    3. Yp says:

      None of the above

    4. marie sophie says:


    5. marta says:

      there is mass in the left hilum – carcinoma?

    6. Mila says:

      There`s a heterogenous mass in the left hilum with ill defineg borders and border calcifications – in lateral image looks like it`s in the posterior mediastinum. The upper segments of LUL are translucent which indicates the dmimisied vascularization. I`d vote for enlarged left pulmonary artery and because of calcifications I`d think about aneurysm. Or maby if the clinical signs are acute we should exclude pulmonar emboli?

      • Dr. Pepe says:

        Nice discussion. Sorry, no calcium was present. And symptoms were minimal.
        Still, you are close.

    7. sameh khodair says:

      A left hilar homogenous opacity of irregular outlines, shows some areas of marginal spiculation and definitely attenuates the lumen of the main left upper lobe bronchus (( bronchogenic carcinoma )) is highly considered

    8. stamos says:

      No trachea or intralobular fissure participation, so carcinoma is excluded. lymph node enlarged vs left pulm.art.dilatation. None of the above though

    9. Murzin says:

      Is it too much to ask for a ct scan :]
      Patient’s age, symptoms and x-rays are not characteristic.
      I would consider ans. 3, although carcinoma (or metastatic lymph node) can’t be excluded.

      • Murzin says:

        Who would state a diagnosis in this case, based on x-ray, without a ct?

        • Dr. Pepe says:

          I don’t expect anyone, including me, to make a diagnosis based only in plain radiographs. But a correct interpretation of the findings helps. In this particular case, the enlargement of the left pulmonary artery on the lateral view excludes carcinoma and TB.

    10. gus says:

      i am not sure if that we see is carcinoma.
      i can see prominent pulmonary outflow tract on frontal view and enlarged both pulmonary arteries on the lateral view. The peripheral pulmonary arteries are normal in size.
      i can’t se well the aortic knob.

    11. kosovo says:

      descending aortic arch saccular aneurism.

    12. polys says:

      It’s a hilar mass and it kind of reminds of an enlarged vessel on the lateral xray. Proposed ddx : pulmonary artery aneurysm, lymphadenopathy, ca.

    13. gaborini says:

      the aorta is rather small. must be some sort of a congenital vascular malformation.

    14. gus says:

      poststenotic dilatation of the left pulmonary artery after chronic pulmonary embolism?

    15. Imran says:

      1. Can bronchoscope
      2. Lymphadenopathy
      3. Duplication / bronchgenic cyst

      Advise:CECT Chest

    16. genchi bari italia says:

      ….la “massa” sembra di “natura” vascolare, presentando delle diramazioni vascolari sul suo contorno.Non puo’ essere TBC perché la TBC è post-primaria in età adulto e dunque dovrebbe presentare un quadro di interessamento parenchimale.Non può essere un tumore ilare perché l’aspetto dei margini è abbastanza regolare e non vi sono turbe di ventilazione polmonare.Resta l’ipotesi di una natura vascolare unilaterale, si esclude pertanto l’ipertensione polmonare, primitiva e-o secondaria.Rimane una ectasia aneurismatica probabilmente esito vasculitico(Becet?).Dirimente ovviamente l’angio-tc con le varie ricostruzioni.

    17. Maria says:

      i vote for enlargement of left pulmonary artery because on profile image the main bronchus is well expanded (no retraction or obstruction). But i guess there is a valvular mechanism of air entrapment more peripherally. Arteritis could be the cause.

      • Dr. Pepe says:

        I agree with you, although the interpretation is simpler: the left artery is enlarged in the lateral view.
        CT on Friday.

    18. Dr. Pepe says:

      Would like to congratulate all of you that made the diagnosis of enlarged left pulmonary artery. Answer and discussion tomorrow.
      Have a nice weekend!

    19. genchi bari italia says:

      …..grazie dott. Pepe….avevo pensato ANCHE ad una patologia congenita vascolare, ma l’età del paziente e la mancanza di segni cardiologici per esempio alla semplice AUSCULTAZIONE, del cuore mi avevano fatto propendere per una origine “acquisita” di tale patologia.Grazie ancora per la lezione!

    20. Dave Calvert says:

      Nice case
      My discussion is different, do we need to do lateral chest on such patients? No matter your interpretation is is the referring doctor always wants CT chest to confirm the lesions, are going back to lateral CXR’s era again? Once you offer a lateral CXR , the referring doctors particularly junior doctors will request lateral CXR on all patients– increased workload and increased radiation!!