Dr. Pepe’s Diploma Casebook: Case 87 – SOLVED!


Dear Friends,

Today I am presenting radiographs of an 83-year-old woman who has had a cough and fever for the last four weeks.
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

1. Acute RML pneumonia
2. RML syndrome
3. RML neoplasm
4. Any of the above



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    14 Responses to : Dr. Pepe’s Diploma Casebook: Case 87 – SOLVED!

    1. Iffat Rehman says:


    2. Jabar says:

      Suspected pneumonia

    3. Jose Caceres says:

      Laconic, all of you!

    4. Andrey says:

      RML syndrome + RLL pneumonia + aortic aneurism

    5. Olena says:

      There are age changes in the lung parenchyma – diffuse sclerosis, and also peribronchovascular component due to inflammation, or lymphogenous spread of neoplasma – canceromatosis ? Aorta deviation in arcus aortae, aorta thoracica and aterosclerotic changes in aorta, the increased volume of heart ventriculus/atrium left (?). Trachea deformation.
      On the right in the right hila projection, more laterally, – increased lung attenuation – lung parenchyma consolidaiton, but according to lateral view – it seeems right middle lobe syndrome (infiltration, atelectasis). Besides, on lateral view suspicion on pleural inflammation reaction with probable start of pleural effusion. Or it could be also pleural fibrosis due to old pleuritis.
      According to that that this is woman – there is no usual both mammae visualization – it could be normal due to age involution, and the shadow of both mammae is beyond FOV or there could be some technical reasons while performing this chestXray (the position of mammae), but it seems like there is no left mammae – maybe, mastectomy ?. If yes, the changes in lung could be neoplastic – mts? with postobstruction pneumonia.
      There is additional shadow on the right chest wall above lateral sinus – it looks like soft tissue mass in chest wall – mesothelioma? which explains probable pleuritis. But the shadow of soft tissue which starts on lung field and follows beyond the chest wall is questionable – it could be right mammae partly resection – the likely shadow could not be seen symmetrically on the left. But on lateral view there is the shadow of mammae so this confuse.
      There are fish-like vertabrae defformation, on the lateral view, especially the one opposite the hila projection – age degenerative distrophic bone changes.

      It seems like there is combination of these three proposed options – because the right middle syndrome could be the result of RML neoplasm with postobsrtuctive pneumonia with lung canceromatosis.

    6. sht says:

      Opacity right base obscuring right heart border = RML penumonia
      Opacity right perihilar region with irregular margin, ? narrowing right bronchus intermed
      Atelectasis pulling right dome upwards anteriorly
      Vertebral collapse at multiple levels.

    7. sht says:

      Right sided subpulmonic effusion?

    8. genchi bari italia says:

      …ci sono due patologie distinte……una è l’atelettasia del lobo medio, visibile in LL….l’altra è la patologia visibile in AP in cui non vi è il segno della silhouette ma patologia della porzione posteriore del polmone….si associano fratture vertebrali, da osteoporosi….

      • Jose Caceres says:

        I think that the silhouette sign is missing because the RML collapse is severe.
        Vertebral fractures were due to ospeoporosis.

    9. sht says:

      if the vertebral compressions are all degenerative, then 2, if the cystic structures are bronchiectasis.

      but margin of right perihilar opacity too irregular to exclude ca