Dr. Pepe’s Diploma Casebook: Case 86 – SOLVED!


Dear Friends,

Today I am presenting radiographs of a 27-year-old male drug abuser who has had a fever for the last two weeks.
Check the images below, leave your thoughts in the comments section and come back for the answer on Friday.


1. Staph Pneumonia
2. TB
3. Pneumocystis
4. None of the above



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    18 Responses to : Dr. Pepe’s Diploma Casebook: Case 86 – SOLVED!

    1. Mauro says:

      None of the above. Klebsiella pneumonia with cavitation and bulging fissure sign.

    2. Albert says:


    3. Pasquale says:


    4. sht says:

      Bulging fissure and cavitations suggest Klebsiella.

      However, two year-old lesion flaring up sounds more like TB!

    5. Adrian says:

      Tuberculosis – old cavity is the source, lobar spread speaks against staph. Pneumocystis would have more spectacular anamnesis.

    6. genchi bari italia says:

      ….pazza idea…..BOOP, da tossicità polmonare all’abuso di farmaci….

    7. Olena says:

      First – it is important to persue the right lateral radiograph to see the type and precise localisation of pathology spread.

      On two year chest radiograph:
      1. there is no evidence of pulmonary vessel system pathology in both lungs
      2. in the lungs there is the evidence of peribronchovascular component, better vizualised in the right lung, especially in medioinferior lung fields, where also is seen the approaching of all the main components of architectonics, what could be the hypoventilation of right medius and/or inferior lung lobus.
      Besides on the level of 2-3 anterior intercostal space there is local shadow of peribronchovascular homogeneous component with partly good and ill-defined margins. There is no evidence of nodulal opacities in both lungs.
      3. The right hila shows the initial sign of deformation due to peribronchovascular component. There is no evidence of bronchopulmonary lymphadenopathy.
      4. From the level of anterior part of 3 rib in prehilar zone to the level of 6 rib layerally, mostly near the lateral chest wall there is thin line probably the shadow of interlobar pleura, which should be seen on the level of 3 rib – in this case it is lower (it could be because of hyperventilation of right lobus superior because of hypoventilation of middle/inferior lobus or on the contrary).
      Both costophrenic angles and both lung apex are not seen and couldn’t be analised. There is no evidence of soft tissue pathology.

      New chest radiograph:
      In addition to previous features, there is inhomogeneous lung parenchyma shadow on the level from anterior parts of 1 to 5 ribs, mainly in lateral zone and partly in prehilar. the superior part of this shadow is more inhomogeneous and the lower part shows lung consolidaion. On the level of 1st rib there is suspicion of cavitation. And it is not seen the right hilar shift due to TB process. There is no evidence of left lung involvement (nodular pattern, consolidation, cavitation etc).

      Staph Pneumonia usually involves lower lobes.
      According to patients anamnesis – drug abuser – it should be HIV/AIDS suspicion.
      If supposing HIV possitive, the chest pathology could be TB, but it do not look like typical TB in such patients (though – for TB it is typical right-sided, and there should be a little signs of transbronchial spread of TB in the left lung due to big lesion in the right lung).
      It should be make differential diagnosis also with Pneumocystis pneumonia – but this could be excluded – it has typicall bilateral spread and it could be Legionella Pneumonia – patchy, peripheral, nonsegmental consolidation initially unilateral and confined to one lobe, but there is no unformation of transplantant operation.
      If HIV-negative – TB

      • Jose Caceres says:

        Dear Olena, I am impressed by your thoroughness.You deserve some help. Imagine that you are looking only at the previous film. What would you think?

        • Olena says:

          Thank You!
          Ok. First af all, I’m not sure that the normal possition of the patient while performing radiograph was hold, because I didn’t see the trachea gap in the middle, and there is additional gap (like trachea) but in paramediastinal right side on that level. And I didn’t see normal anatomical airways division in the right hila because of mentioned earlier peribronchovascular component.
          Remarkable is the right lung parenchyma, which shows poor peripheral vascularity throughout the lung area and decreased lung vascularity in the right lobus superior and paramediastinally over the diaphragm – “Parallel” or “divergent” patterns of vascular reorientation – the evidence of right lobus inferior atelectasis and due to this mentioned shift down of minor fissure.
          The both lung apex can not be analised, what is important, because there could be signs of old inflammation process.
          The most problem is that shadow on the level of anterior part of 2 rib – it seems that there is some nodular pattern or it is the aggregation of smaller nodulus in secondary pulmonary lobule, because it seems that there is a gap of bronchi in the middle of that pattern and some vessel shadows peripherally this nodul.
          It is solitary lesion and differential diagnosis is wide – tuberculoma, mts, sarcoidosis, Wegener’s granulomatosis, peripheral cancer, fungi lesion, aspergilosis – the two last are also typical for drug abusers.
          It looks like this process is chronic/long lasting in this patient.
          That is what I think.

    8. khan says:

      i think its none of the above.
      ===if v c the two yrs old xray it is just showing small cavitating lesion in right mid lung zone which has increased in number in new xray—-considering its multiplicity and the H/O IV drug abuser these favor the septic emboli.
      ===Regarding opacifiction of the right upper and mid zones it seems to be superadded consolidation which can be any organism which IV abusers are prone to.But not specifically klebsiella or staph because the fissure which seems to be bulging by consolidation is in actual at the same position as was 2 years ago. And this bulging position of fissure 2 years ago seems to be due to emphysematous changes in the lung which IV abusers are also prone to develop.

    9. Khan says:

      Ya differentials include. TB and staph

    10. ivan says:

      I would say that there is underlying bronhihal atresia which was complicated later on.