Dr. Pepe’s Diploma Casebook: Case 54 – SOLVED!


Dear Friends,

Welcome to this week’s case. Radiographs belong to a 43-year-old male with chest pain. Leave me your thoughts and diagnosis in the comments and come back on Friday for the answer.


1. Hypertrophic cardiomyopathy
2. Mitral disease
3. Non-cyanotic congenital heart disease.
4. None of the above



Click here for the answer

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    27 Responses to : Dr. Pepe’s Diploma Casebook: Case 54 – SOLVED!

    1. Murzin says:

      I’ll tryo to be the first one this week.
      So first of all I think correct answer is 4. none of the aobve because in my opinion the heart itsefl is quite intact.
      The morfology of changes makes me think of pericardial mass.
      In this case with history given I think I would consider a malignancy although it is not so common.
      Perhaps it could be neoplastic pericarditis.
      On the lateral mage I can’t see the descending aorta- is it there? If not I would consider pathology among aorta.

      Maybe a little hint- although it is quite soon.

      PS Are You coming to Warsaw for the next EDIR ?

    2. branka says:

      there is enlargement of the right heart which we can see on the lateral view,it is filling more then 1/3 of retrosternal space.In mitral stenosis we can see left atrial enlargement( double density in a heart silhouette)and pulmonary hypertension.Here this is not the case.In non-cyanotic heart disease there would be changes in pulmonary circulation (ASD,PDA,APSD,coarctatio aortae etc. ).On a film there is no vascular changes. I would go with hypertrophic cardiomyopathy (right heart). Or maybe is something else.. 🙂

      • branka says:

        dont be to hard to me too,as mr.jose said..l am still a resident.. 🙂

        • Dr. Pepe says:

          For a resident you didn’t perform badly. As you will see tomorrow, it is a mediastinal tumor simulating cardiomegaly.

    3. rajesh says:

      Mitral disease

    4. genchi bari italia says:

      ….vi è una congestione del piccolo circolo, con ipertrofia ventricolare sx; dilatato il tratto ascendente dell’aorta mentre è scarsamente visibile( perchè ipoplasico) il tratto discendente….ci sono incisure sul bordo inferiore di alcune coste, bilateralmente(ipertrofia art. intercostali)…..Diagnosi finale: coartazione aortica post-duttale. NB. Il Bari è in netta ripresa in campionato…..aspettiamo acquirenti anche dalla Turchia!

      • genchi bari italia says:

        ….quello che mi ha fuorviato la diagnosi è che hai proposto tra le possibili diagnosi, solo patologie cardiache…tralaltro sono stato forse fuorviat0 da presunte irregolarità sul margine costale inferiore…però, però però….la morfovolumetria cardiaca è “insolita” per qualunque cardiopatia…inoltre lo spazio retrosternale è “occupato” da una massa( pensavo all’ectasia pre.stenotica di una cortazione)….rivedendo la diagnosi finale direi che è una delle 4 cause di masse di tale comparto e siccome”scende” a rivestire il cuore, io penso ad un Timoma.

    5. Jose M. Esteban says:

      In my humble opinion, there is an enlargament of the left ventricle, with the right heart with a normal size and morpphology. Aorta and pulmonary arteries seem normal. I would bet on a mitral disease.
      P.S. It is my first time here, so don’t be too hard with me…

      • Dr. Pepe says:

        As a welcome present, I will give you a tip: in the plain film it is difficult to determine which ventricle is enlarged, unless it is obvious. Perhaps is not a ventricle…

    6. Alaa says:

      2. Mitral disease, because the left atrium is enlarged.

    7. gaborini says:

      is the pulmonary vasculature increased? If so, then together with the left ventricular enlargement a ventricular septal defect might be an option.
      At the same time there is insufficient inspiration, which can simulate increased vascularity.

    8. Anna says:

      Heart shadow is enlarged, but asymmetrically, it’s not suppose to be neither mitral configuration nor HCM. Congenital heart disease in unlikely because of normal pulmonary vascularity.
      I’m agree with Murzin, abnormality is not in the heart itself. It could be mediastinal mass, possibly pericardial cyst or teratoma.

    9. Maria says:

      I think that we should include an intracardial mass such as a mixoma or a sarcoma in our ddx. Moreover i believe there is a small gap at the continuation of the posterior segment of the left diaphragram on profile image.

    10. John says:

      I think the answer is D. Could be a Tetralogy of Fallot?

    11. gus says:

      i think the mass is extra cardiac. there is not realy enlargment of the heart.
      the hulum is not enlagment,the pulmonary vasculature is not increased , there is not widening of the angle of tracheal bifurcation. the mass is located in anterior mediastinum.

    12. CroResident says:

      There is obliteration of retrocardial space on profile view.
      On PA view tracheal bifurcation seems normal to me.
      Additionally, on profile view through cardial sillhouette, it seems there is a lobulated contour of a mass, borders most discernible at the height of the tracheal bifurcation so I would say a mass is positioned in middle anterior mediastinum.Left ”heart” contour could be contour of a large mass, i see that the left contour reaches above aortic arch which on PA looks just fine. Differential diagnosis: I would go for thymic origin or germ cell tumor (e.g. teratoma).Regards 🙂

    13. Carlos says:

      I think the right answer is 4. No left atrium enlargement is against 1. and 2. And again for option 3. no cardiac chambers enlargement + the pulmonary arteries and veins look normal.
      Probably the key for the diagnosis is the hilum overlay sign on the left (pulmonary artery <1 cm medial to the cardiomediastinal contour), this sign usually tells us that a mediastinal (anterior, middle-posterior) or paravertebral mass is present. The retrosternal space is occupied, so in my opinion there is a thymic neoplasm, lymphoma or germ cell tumor present. A vascular lesion such an aneurym can cause this sign but I don't think there is any.

      This is the first time I wrote a comment in this blog, so don't be very tough with me,… just in case 🙂

    14. Dr. Pepe says:

      As the answer will be posted tomorrow, I can give you a diagnosis;
      correct answer is: mediastinal mass simulating cardiomegaly.
      Congratulations to Murzin, who was the very first to suggest the diagnosis

    15. adin fischer says:

      and that’s so crazy these days, really?
      could be myopathy equally fine;
      here’s what happened in Romania; after all CT craziness with people like me refusing to go back to Xray and perform only head CT and no head Xray a famous sports player got hit by a car in some accident , CT wasn’t working and Xray was done was interpreted as normal cause some good old docs know how to do that and refused to send patient to some CT, it was hemorrhage and patient died and legal issues sprang over the case and good old radiologists and good old radiological science and good old Xray was not only useless and stupid but also detrimental like mortal….so why can’t we replace the good old crap with new bright good science and the useless means that proof wrong?

      • Dr. Pepe says:

        Wow! You have to stop drinking so much coffee!
        Seriously, I don´t think anybody would be happy with a chest X-ray in a patient with significant trauma.
        Blame the not-working CT unit, rather than the radiologist.