Dr. Pepe’s Diploma Casebook: Case 53 – SOLVED!


Dear Friends,

Today I am presenting radiographs of a 36-year-old woman with shortness of breath increasing over the last three months. Examine the image below and leave me your thoughts and diagnosis in the comments. Come back on Friday for the answer.


1. Metastatic disease
2. Sarcoid
3. Interstitial pneumonia
4. None of the above

36-year-old woman with shortness of breath

36-year-old woman with shortness of breath

Click here for the answer

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    Mar 2014
    DISCUSSION 26 Comments

    26 Responses to : Dr. Pepe’s Diploma Casebook: Case 53 – SOLVED!

    1. gaborini says:

      the Kerley-lines suggest either pulmonary congestion, or lymphangitic carcinomatosis.
      Due to the normal configuration of the heart and lack of apparent pleural fluid, it’s probably lymphangitic carcinomatosis.

    2. gus says:

      I agree with gaborini(breast ca?)
      i can’t see osseous metastasis.
      That i can’t understand is where is going these subclavicular catheter.

    3. gus says:

      i think the catheter is the key.
      Is lymphatic catheter?
      The catheter was before diagnosis?

      • Dr. Pepe says:

        Good observation. It is a central venous catheter that has been pushed pass the right atrium. It is an accident and has no other significance.

    4. genchi bari italia says:

      ….il quadro radiologico è quello di una malattia granulomatosa, per la presenza di micronoduli, prevalenti nel polmone medio-inferiore;non ci sono adenopatie nè ilari nè mediastiniche;non ci sono immagini cistiche( da air-trapping a causa di infiltrazioni linfoidi peri.bronchiolari)…,per queste ragioni si esclude rispettivamente , la sarcoidosi e la LIP(polmonite interstiziale linfocitica)…si vedono inoltre strie rx-opache, trasversali, Kerley-like in assenza di cardiopatia( probabilmente infiltrazione cellulari nei vasi linfatici, sub-pleurici)…..pertanto alla luce del contesto anamnestico di eventuale cr, la diagnosi piu’ probabile è linfangite carcinomatosa.

    5. Rui Fernandes says:

      Intersticial pneumonia.

    6. maria says:

      Lymphangitic carcinomatosis

    7. Vilma says:

      I agree with Gaborini, it can be lymphangitic carcinomatosis.

    8. selma says:

      Interstitial pneumonia.
      How is her lateral chest graph?

    9. Luigi Cocco says:

      Fibrosi interstiziale idiopatica: No carcinosi endolinfatica diffusa!!!!!!

    10. Murzin says:

      Hello, IMHO
      the severity of this case is caused by inconsitency of the x-ray appaerence and clinical image and demographics.
      Difuse fibrosis with interlobular septal thickening- in the right lower lobe the changes have tendency to consolidate (really can’t say if anything is hiding there)- this made me think Intertitial neumonia but the patient’s age is not right.
      In the upper poles I think I can see discrete nodular pattern that could be caused by Lymphangitis carcinomatosa or Sarcoidosis- no apparent npl diseaserules out LC so I’m left with Sarcoidosis although the distribution of changes is atypical.

      Unless this patient has an autoimmunological disorder like SLE?

      • Dr. Pepe says:

        How often do you see widespread Kerley lines in sarcoidosis vs. lymphangitic carcinomatosis?
        What is meaning of IMHO?

        • murzin says:

          IMHO- in my humble opinion :]

          Kerley lines are way more often in lymphangitic carcinomatosis but:
          -would they be so diffuse and symmetrical and do We have a known malignancy?
          -sarcoidosis has many faces and this appaerance would be quite a rare case as the previous ones 😉

          can’t wait for the answer

          • genchi bari italia says:

            ….per la Sarcoiodosi, che effettivamente può presentarsi UNICAMENTE, con un quadro parenchimale, ci sono i segni clinici di una patologia Sistemica, nonché i risultati sierici di aumento ACE, nonché positività del test di Kveim….secondo IMHO….

          • Dr. Pepe says:

            Sorry to disagree with you. In my not-so-humble opinion (quoting Snoopy,it’s difficult to be humble when you are as great as I am), widespread lymphangitic carcinomatosis is not uncommon in G.I. tumors. It is very uncommon in sarcoidosis, in my experience.

            • genchi bari italia says:

              ….la risposta che hai data era per me o per Murzin?…..io dicevo che non poteva essere sarcoidosi,( solo parenchimale) anche perchè non hai citato eventuali segni sistemici della sarcoidosi, nonchè eventuali dati di laboratorio( ACE…B2microglobulina…BAL…) che accompagnano una Sarcoidosi…per me la diagnosi, come nel primo commento è linfangite carcinomatosa

            • Murzin says:

              Also in stage IV? I haven’t ever really seen one- I thought that fibrotic in sarcoidosis changes could have this appaerance… also in sarcoidosis.
              I’ll surely remember that.
              Were the shortness of breath and x-ray image first findings in this case or the malignant process was well known all the way ?

          • Dr. Pepe says:

            To Genchi Bari: the answer was obviously for Murzin.
            To Murzin: this chest was pre-op. We suspected GI carcinoma and investigated the clinical history.
            Patient had a gastric carcinoma. Her doctor was informed and intervention suspended.

    11. Eugenio says:

      The Kerley B lines suggest interlobular septal thickening.

      The normal heart and the demographics go against pulmonary edema.

      The absence of upper and middle lobe compromise go against sarcoidosis, but the sex, age and symptoms do correspond.

      Lymphangitic carcinomatosis is a good option for a 36 years old woman, in the context of breast cancer mainly.

      An interstitial pneumonia can not be excluded, but I would like ground glaas opacities. I would love a HRCT.

      I pick lymphangitic carcinomatosis as my first option.


    12. francesco says:

      I agree with the group suggesting lymphangitic carcinomatosis.

    13. Ibrahim says:

      Chest X Ray PA view
      Diffuse, bilateral reticulonodular opacification with Kerley B lines is noted especially in the right lowr zone suggestive of lymphangitic carcinomatosis.
      The primary sites are the breasts (mostly) or GIT.

    14. Dr. Pepe says:

      Friday is here and I want to thank you all for participating. Congratulations to Gaborini, who led the group that made the correct diagnosis.

    15. Tomas says:

      Interstitial pneumonia

    16. adin fischer says:

      and there’s not only one single book or a collection of books that could consistently be used for training…some sort of Trojan horse that has infected all sources ok knowledge rendering us retarded…