Dr. Pepe’s Diploma Casebook: Case 58 – SOLVED!


Dear Friends,

I am back from vacation and ready for new challenges. Present images belong to a 70-year-old man with cough and fever. Leave your thoughts and dignosis in the comments section and come back on Friday for the answer.


1. Carcinoma of the lung
2. Tuberculosis
3. Pneumonia
4. None of the above



Click here for the answer

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    Jun 2014
    DISCUSSION 25 Comments

    25 Responses to : Dr. Pepe’s Diploma Casebook: Case 58 – SOLVED!

    1. gaborini says:

      RUL atelectasis with Golden S sign, suggesting central carcinoma of the lung. Or any other central lesion, for that matter.

    2. genchi bari italia says:

      ….gentile collega…a prima vista sembrerebbe una atelettasia del lobo polmonare superiore dx, con versamento pleurico….tuttavia la immagine tracheale non è attratta omolateralmente ed anzi sembra medializzata, …inoltre è apprezzabile la linea paracavale e paratracheale….per cui farei un confronto con eventuali precedenti e, prima della TC ,risolutiva, farei ciclo di terapia antibiotica(febbre) e rifarei un rx- di controllo ….

    3. Laurens says:

      Superior displacement of horizontal fissure with RUL triangular opacity. On lateral view widening of retrosternal stripe. Compensatory hyperexpansion of right middle and lower lobe (intercostal space widening in the middle and lower zones on the right) and elevation of right diaphragm. These signs indicate right upper lobe atelectasis. Right pleural effusion. Medial part of horizontal fissure looks convex so I will agree this could be reverse S sign – possible carcinoma of the lung causing postopstructive atelectasis. In differential I would add enlarged lymph nodes,metastases or mediastinal tumour for causing the obstruction.

    4. gus says:

      i think the opacity is in pleural space.
      how about the left clavicle? there is relationship?

      • Dr. Pepe says:

        Clavicles may present weird apperances, depending of their position. This one is OK.
        Why do you think that the opacity is pleural?

        • gus says:

          there is not evidence of atelectasia on the right side. it looks like but is not.
          in leteral view the opacity is continued from the base to the apex with smooth borders and with out fluid levels.
          DD pleural mass?

    5. thomas borg barthet says:

      its a carcinoma of the lung, what we see if the golden s sign, its a lobar collapse with possible complicating pneumonia with underlying carcinoma.

    6. Maria S. says:

      The RUL opacity I believe is not due to atelectasis of central origin. The right hilum on the profile x-ray images no apparent central mass.The trachea seems to have an indented contour on the right and left. Air delineates the upper right mediastinal line. Mild hyperinflation of the right middle and lower lung zone.The right hemodiaphragm is elevated and abnormal thoracic and epidiaphragmatic pleura is evident (fluid? pleura thickening?). The left hemithorax also presents findings: there is an opacity above the aortic knob (LUL atelectasis?) in the PA x-ray and an apical cap in the left apex. Dr Pepe,is there a history of plombage/ collapse therapy???? Previous Tb?

      • Dr. Pepe says:

        No history of plombage , nor anything else. When I posted the case I thought it very straightforward; but I guess I was wrong.

    7. muris says:


    8. The mediatine isn’t displacement. For correlation and simtomas Pneumònia Of Superior Right Lobul

    9. Karla says:

      My first impression is RUL atelectasis with Golden S sign, regardless, it could be plural effusion as the costophrenic angle is also obliterated.

    10. Jose M. Esteban says:

      We should be aware of the symptoms, don’t just focus on the X ray signs. Atelectasis and fever, among the suggested diagnosis, could be found in tuberculosis.

      • Dr. Pepe says:

        I disagre with you. Sometimes, the signs can be a strong indicator of the disease (as in this case).

    11. Paula van kerckhoven says:

      En la radiografía de ve una opacidad homogénea de límite definido compatible con una atelectasia del lobulo superior, signo de golden. Al haber una compresión intrínseca o extrínseca sobre el bronquio se produce la atelectasia. Puede corresponder a tuberculosis o un tumor (adenopatia o compromiso por masa)

    12. Fares says:

      Postobstructive atelectasis due to a mucus plug in the right superior lobar bronchus in a patient has COPD.

    13. muris says:


    14. muris says:


    15. Dr. Pepe says:

      I believe I can say that the case corresponds to a RUL collapse with a Golden sign.
      More images tomorrow.
      Congratulations to all winners!

    16. gus says:

      Sorry professor i think i see phantoms on the films. 🙂
      It was too easy to be true. but a good lesson for next time!

      • Dr. Pepe says:

        Remember that Dr. Pepe’s mission is to teach in order to prepare people for the Diploma. Cacere’s corner shows difficult cases, for fun.