José Vilar and Friends Case 21 (Update: Solution!)

Hello everybody,

I hope you enjoyed your holidays wherever you are. I wish you a wonderful new year!

After case 20 (Tracheobronchomegaly) that was very well interpreted by those who dared to send a diagnosis, here is another challenge.

Preoperatory chest radiographic study. No significant clinical symptoms.

Additional information:

Ok friends, some of you mentioned situs inversus, so I am adding some more data to see if you can define better the findings.

Click here for the answer

Solution:

The PA and lateral chest radiographs show an air/fluid under the right hemidiaphragm. Fluid is not usual when the colon is interposed (Chilaiditi). This is the typical image of the stomach, but on the wrong side. The heart is in the normal position.

A not so obvious finding is the slight prominence of the azigos. (Arrow) and the fact that both hila seem to be at the same height.

CT: The sagittal images show that both lungs are very similar with one major fissure and no minor fissure. This is, as very well indicated by Pppp in the blog, a Left Isomerism: The patient has two “left lobes”. This is why the hila are higher since in the normal left lung the pulmonary artery is above the bronchus.

Furthermore, the abdominal CT images (that I did not show you) show several findings:

Multiple round enhancing nodules in the left hypochondrium: These are spleens: Polisplenia. (Yellow arrows)
The liver is in the center/right.
The stomach is in the right side.
The head of the pancreas, and the gallbladder( Red arrow) are in the midline.
Interruption of inferior vena cava with azigos continuation, which explains the azigos enlarged in the PA chest radiograph. (White arrows)

In summary; this patient has a congenital anomaly with abnormal disposition of several organs and associated malformations.

Heterotaxia or situs ambiguous. ( Heterotaxia means “different arrangement”).

In situs inversus, mentioned by some of you, the heart and the stomach are in the right side and the largest lobe of the liver in the left, (Viscero atrial situs following Van Praagh). This is seen in this other case.