Dr. Pepe’s Diploma Casebook: Case 92 – SOLVED!


Dear Friends,

Today I am showing radiographs of a 62-year-old man with moderate dyspnoea. No acute symptoms. What do you see?

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



Click here for the answer

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    16 Responses to : Dr. Pepe’s Diploma Casebook: Case 92 – SOLVED!

    1. Mauro says:

      Right lung volume loss, probably secondary to a neoplasm involving the right main bronchus. Fracture of the 4th left rib, laterally, with lung herniation as a sequela.

      • Dr Pepe says:

        Good approach. But: how many times have you seen herniation of the lung after fracture of one rib?

    2. Diogo says:

      Right lung volume loss and diffuse interstitial reticular opacities. Asymmetric fibrotic lung disease?

      The left hilum looks distorted but this could be due to the mediastinum shift.

      I agree with Mauro about left rib old fracture and lung herniation.

    3. Borsuk says:

      there is significant volume loss of right lung with mediastinale shift to left and diaphragm elevation.
      Massive fibrosis – maybe after radiation terapy? some history needed.
      I agree with Mauro about lung herniation with rib fracture.

    4. Aggeliki says:

      Tumor right hilum wth necrosis after radiotherapy with volume loss of right lung with reticulonodules pattern,elevation of right diaphragm ,Shift of mediastinum to the right

    5. tekwani says:


    6. Anna says:

      Reticulonodular opacites on right side. Right hilum tumor susp. Mediastinum shift on right side. Right diaphragm lift up. Fracture of the 4th left rib-meta susp. Aortic arch dilatation.

    7. Tamara says:

      Significant volume loss of right lung with mediastinale shift to right and diaphragm elevation.
      Cause probably fibrosing mediastinitis, Idiopathic
      I agree with Mauro about left rib old fracture. Osteoporosis

      Necessary CT

    8. Anna says:

      Reticulonodules opacieties on right side, status post radiotherapy. Right hilum Tu-suspect. Shift mediastinum on right side.Aortic arch dilated. Fracture of the 4th left rib-meta suspect with herniation.

    9. Diogo says:

      Unilateral left lung transplantation for fibrotic lung disease with lung herniation?

      • Dr Pepe says:

        Congratulations! Well done!
        Actually, all the information is in the radiographs. It is a matter of interpreting it correctly:
        a) most common cause of herniation: surgery
        b) disparity between both lungs: transplant
        See Caceres’ corner case 56

    10. genchi bari italia says:

      ….pregiatissimo Professore….iperchiarezza del polmone sx, bolla di enfisema sottocutaneo….a dx, perdita di volume del polmone, risalita della cupola diaframmatica, con shift cardiomediastino, da probabile cr ilare…

    11. Sabih Mirza says:

      Raised right hemidiaphragm. Also decreased right lung volume, ipsilateral mediastinal shift
      In addition there is increased interstitial thickening in the right lung.

      Fracture at the left sided 4th rib, focal pleural thickening and also a pocket of air lying outside the left lateral chest wall in the axillary region suggests lung herniation.

      Most likely the findings are due to trauma

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