Dr. Pepe’s Diploma Casebook: Case 52 – SOLVED!


Dear Friends,

Today I am presenting radiographs of a 43-year-old woman with moderate dyspnoea. Disregard the widening of the right superior mediastinum, secondary to long-standing goiter. Leave me your thoughts and diagnosis in the comments sectiona and come back on Friday for the answer.

1. Thymoma
2. Heart disease
3. Lymphoma
4. None of the above

43-year-old woman with moderate dyspnoea

43-year-old woman with moderate dyspnoea

Click here for the answer

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    28 Responses to : Dr. Pepe’s Diploma Casebook: Case 52 – SOLVED!

    1. dominik says:

      Dear Profesor Caceres and Dr Pepe,

      perhaps this is my last post before EDIR

      In this erect pa chest xray is:
      – markedly seen vascular pattern in lower and partially medial pulmonary fields bilateral
      – bilater cephalisation of vascular pattern in upper fields
      -less vascular pattern on the peripherial parts of the lungs
      -the right pulmonary artery look enlarge, i think more then 16 mm
      – the left vascular hilum is impossible do diagnose
      -the upper right mediastinum is enlarged unilateral;sail sign?thymoma?
      – marked left round shadow of the left middle mediastinum.
      -CH ratio looks ok
      -no bone destruction
      -no metal parts which can suggest an surgical intervention

      – pulmonic stenosis ( with or without asd )
      – pulmonary artery hypertension
      – mediastinal mass – sail sign ? thymoma ( there is no calcification, no marked tracheal shifting ) or thyroid goiter.

      • Dr. Pepe says:

        Good luck! When meeting the examiners, tell them that you are a friend of Dr. Pepe.

        • dominik says:

          thank you!!!!! i ll do for sure.
          i have learned a lot immersing my self in all cases !
          any tip for diagnosis of this patient.

      • Dr.GSPG says:

        Agree a lot with the you dear.
        But it looks like pulmonary venous hypertension with loss of pulmonary bay- D/D MS and other causes of pulmonary venous hypertension.

    2. dr. Darkside says:

      Dr Pepe…I miss the lateral view…may you show it to us?

      I observe a mediastinal widening, with bulging of the aortic line, so there is not a aortopulmonary window. Edges are smoth. The hila and the cardiotoracic silhouette seems not pathological to me. Parenchima also looks normal. So, as we wait for the lateral rx, I’d think of vascular disease( aortic aneurisma…), but by now, thymoma or lymphoma cannot be discharted, so I guess I need more tips, then…

    3. gaborini says:

      enlarged left pulmonary artery

    4. genchi bari italia says:

      ….carissimo dr Pepe….iniziamo con la clinica:dispnea….è di origine cardiaca(= disturbo di circolazione del piccolo circolo) oppure è di origine tracheo-bronchio-respiratoria?…i polmoni sono normo-espansi e normo-perfusi, per cui penso di escludere la causa cardiaca….rimane la seconda ipotesi….la “silhouette” vascolare del mediastino è alterata, lasciando pensare che è quella la causa….l’ilo di dx, vascolare , è normale….rimane l’ilo vascolare di sx che non è valutabile….conclusione “anello vascolare” dato dalla “anomala origine dell’arteria polmonare di sx,con compressione tracheo-bronchiale….vedremo la TC con le varie ricostruzioni…..NB. il mio Bari è fallito ,si va ora in tribunale per la vendita del titolo…..siete interessati?

      • Dr. Pepe says:

        Sorry, not smart enough to be rich and buy Bari. Do you really think that the pulmonary vasculature is normal?

        • genchi bari italia says:

          …allora hai fatto pretattica per “confondere” le idee all’avversario….Scarsa definizione del profilo cardiaco di dx, con ombra cardiaca “scivolata” a sx…..prominenza del cono della polmonare….”strano orientamento delle coste….HAI NASCOSTO la LL, perché la diagnosi sarebbe stata così facile…Straight back Syndrome…..

    5. Priyank Gupta says:

      Right heart border not visualised. Posterior ribs more horizontal & anterior ribs more vertical.Possible diagnosis – Pectus excavatum..
      Need ur wishes & last minute tips for the exam!! 😛

    6. bansal k says:

      Frontal chest radiograph reveals prominent pulmonary conus (convex margin) with dilated central pulmonary arteries and peripheral pruning sugggestive of pulmonary arterial hypertension.Also there is suggestion of right ventricular contour of apex s/o right ventricular hypertrophy. However , cardiac size is normal.
      There is no focal lung parenchymal lesion.
      Bilateral CP angles are clear.
      There is widening of right superior medastinum with convex lobulated outline. But as suggested by you to ignore it as it is due to long standing goitre.

      • Jose Caceres says:

        I disagree about the peripheral pruning. Look at the vessels of the right lower lobe

    7. Dr Zubinovich says:

      Dear Dr.,
      I can add two things to other answers.
      1/ Widening of rt.sup.mediastinum which seems not related to the thyroid gland because the trachea is not displaced.(mediastinal mass probabaly related to neural tube)
      2/prominence of pulmonary trunk(R/O pulmonary HTN )although straight back syndrome or pigeon chest cant be rulled out.

    8. drhoanghanh says:

      Trunk of pulmonary artery is prominent with asymetric pulmonary vasculature, right side more prominent than left.

      • Dr. Pepe says:

        If you you a prominent pulmonary trunk and increased pulmonary vasculature, what do you think of?

    9. milind says:

      pectus excavatum till proved otherwise…..

    10. murzin says:

      What I see is left sided aortic arch, prominent pulmonary trunk nad increased vasculature suggesting PDA or in this case a less severe aorto- pulmonary shunt…
      Coexistence of most probably thyroid goiter…

      Good luck for the Exam-Takers!!!

    11. genchi bari italia says:

      …..grazie per la bellissima lezione! il caso insegna inoltre la validità della regola KISS….avevo pensato a questa diagnosi, dimenticando questo insegnamento …e fatto una diagnosi molto più difficile e fantasiosa! NB:Spagna-Italia 1 a o…goal di Pepe su assist di Caceres !!!!!!!

    12. Dr.GSPG says:

      Agree a lot with most of the previous comments.
      However, there is no signs of pulmonary arterial hypertension. This thought of pulmonary arterial hypertension is confusion the issue. The presence of cephalization of the flow and the likely dilated right descending pulmonary artery should suggest pulmonary venous hypertension.
      There is also loss of normal pulmonary bay.
      But it looks like pulmonary venous hypertension with loss of pulmonary bay- D/D MS and other causes of pulmonary venous hypertension.

      • Dr. Pepe says:

        Sorry, I disagree with you. The radiologic signs of pulmonary venous hypertension are reversed flow, with grater caliber of upper vessels, compared to the lower ones. The case presented shows the opposite: the lower vessels are much more prominent than the upper ones.

        • Dr.GSPG says:

          Thanks for replying.
          I again carefully looked at the X-Ray-I think I must revise my opinion- you are right in observing that the lower zone vessels are wider then the upper zone vessels- thus my conclusion, that there is cephalization of the pulmonary flow is probably erroneous. So suggesting pulmonary arterial hypertension (due to increased pulmonary artery flow) is prudent. However there is no peripheral prunning.
          Thanks for nice case!

    13. allagrasan says:

      Promint pulmonary trunk