Dr. Pepe’s Diploma Casebook: Case 91 – SOLVED!


Dear Friends,

Today I am showing images of a 48-year-old man with two brain lesions and a pre-op chest radiograph. What would be your diagnosis regarding the chest?

Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.


1. Carcinoma
2. Hydatid cyst
3. Pulmonary infarct
4. None of the above



Click here for the answer

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    15 Responses to : Dr. Pepe’s Diploma Casebook: Case 91 – SOLVED!

    1. Olena says:

      on PA view the increased vascularity in hilar and prehilar zones in both lungs and oligemia on the peripheral zones (Westermark sign), but more seen in left lung

      On the left on the level of anterior part of 7-8 ribs above the costo-diaphragmal sinus there is opacity with smooth well-defined medial and lower contours, which adjacent to the chest wall laterally, in the middle of the shadow of this opacity suggesting calcification within it?

      There is suggesting of enlarged vessel on the left (Fleischner sign)

      Considering the asymptomatic case
      suggesting – 3.Pulmonary infarction

      • Olena says:

        According MRI – there are to lesions that show the contrast media enhance incomplete ring-like shape with a huge perifocal edema
        suggesting demyelination (but the presence of edema could exclude it)or
        Intracranial haemorrhage due to the changes in lung parenchyma because of venous thrombosis

    2. khan says:

      there is broad based soft tissue opacity in left CP angle making obtuse angle with no obvious aggressive features–extrapulmonary likely pleural based.–can be pleural fibroma

      Right axillary region faint rim calcified lesion–can be lymph node.
      rest of chest seems to be fine.

      regarding brain lesions they are showing incomplete ring enhancement favoring demyelinations.

    3. Uli says:

      Brain abscesses associated with vascular anomaly in a lung?

    4. Uli says:

      Rendu Osler Weber, pulmonary complications of shunting and brain abscess

    5. sht says:

      Brain MRI: Two round lesions in cortex with ring enhancement and surrounding edema.

      CXR: Round opacity with smooth margin left base, ?anterior as dome unaffected.

      Another soft opacity with smooth margin in the right paratracheal region.

      Ans: None of the above.

      • sht says:

        Does the response ‘carcinoma’ cover secondaries?

        In yes, then ans could be carcinoma.

    6. Doyin says:

      Rounded soft tissue opacity in the left lung base with calcific focus in centre, suggestive of calcified granuloma due to healed tuberculous infection.
      Ring enhancing lesions in the parietal lobe with surrounding edema, suggestive of tuberculomas.
      Overall conclusion is that of intracranial tuberculomas from reactivated pulmonary tuberculosis.

    7. genchi bari italia says:

      ….la risposta dovrebbe essere la 4: nessuno dei precedenti….in base all’rx torace, si può escludere il CR ed il tubercoloma….ma anche la cisti idatidea polmonare perchè la formazione sembra di pertinenza pleurica….le due formazioni all’rm presentano cararatteristiche di natura infettiva, “matura”, come da ascessi e-o granulomi infettivi….come è il profilo immunologico del paziente ?…..CAMPEONES!!!!Felice per il Barca….noi a Bari stiamo soffrendo…..andiamo ai play-off….

    8. Dr Pepe says:

      Late in the day, giving credit to Uli, who made the correct diagnosis.
      Images and final answer tomorrow

    9. Cornilius Mushambi says:


    10. Joe Lowry says:

      PAVM with brain abscess