Solution:

Remember this is a patient with psychiatric problems, and in this case this may help. Let’s see…

In the PA chest radiograph the obvious finding is the presence of metallic densities in both lower lobes and the cardiac silhouette. The yellow arrows show that these densities seam to adapt to the heart and may show some type of “fluid level “dependency.

Metal can arrive to the lungs either through the bronchi (aspiration) or via the vascular system ( embolization).
In the times of bronchography it was common to see dense lipiodol contrast in the lungs, usually showing the outline of the bronchial walls.
But this is not the case. This is a pathology that I have only seen three times in my life and is easily recognizable if you have seen it before as in my case.

Mercury embolization.

Mercury embolization has been described in patients that intend suicide by injecting themselves with mercury. It also has been described as a potential method to attain muscular strength in athletes.

The three cases I have seen were related to psychiatric problems with suicidal attempts.
The image is always very similar with multiple metallic densities in the lower lobes especially (where there is more flow obviously) and also within the heart in the vicinity of the endocardium.

You can see the similar findings in this other case. Branching vascular patterns are seen as well as accumulation of mercury in the right ventricle.

Teaching point: If you ever see a case like this, you will probably make the diagnosis. The aunt Minnie approach often works.

Reference: Celli et al: Mercury embolisation in the lung: N Engl J Med 1976; 295:883-885